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HEALTH WORK IN THE 
SCHOOLS 



BY 



ERNEST BRYANT HOAG, M.D. 

Director of School Hygiene for the State 
Board of Health for Minnesota 



LEWIS M. TERMAN 

Associate Professor of Education, Leland Stanford Jr. University 




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BOSTON NEW YORK CHICAGO 

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V 






COPYRIGHT, I914, BY ERNEST B. HOAG AKD LEWIS M. TERMAN 
ALL RIGHTS RESERVED 



CAMBRIDGE . MASSACHUSETTS 
U . S . A 



AUG-Si9l4 

©CLA376928 



TO 
HENRY M. BRACKEN, M.D. 

SECRETARY OF THE STATE BOARD OF HEALTH 
FOR MINNESOTA 



EDITOR'S INTRODUCTION 

Educational Hygiene has four chief divisions: (1) 
The Hygiene of Physical and Mental Growth; (2) 
Health Supervision in the Schools, including methods 
of health observation and teaching; (3) the Hygiene of 
Instruction; and (4) the Hygiene of the School Plant. 

The first of these divisions has been treated by one of 
the authors of this book in The Hygiene of the School 
Child, which has appeared as an earlier number of 
this Series, and the third, by the same author, is in 
preparation. The fourth division is to be covered by 
another author, and is also in preparation. 

The present volume deals with the problems in- 
volved in health supervision, health examination, and 
hygiene teaching, — in other words, with the second 
of the above divisions; and it is hoped that it will con- 
tribute materially to the standardization of health 
supervision and to the broadening of its scope. Every 
one must realize that a great amount of what goes by 
the name of "medical inspection of schools" can be 
called health work only by courtesy. All along the 
line, among superintendents, teachers, school nurses, 
school boards, and even school doctors, education is 
needed which will lend a broader vision to the purpose 
and possibilities of genuine health supervision. 

Special emphasis has been given by the authors to 



i 



viii EDITOR'S INTRODUCTION 

the part played by the teacher in school health work. 
To this end, two chapters have been prepared (v and 
vi) for the purpose of assisting teachers in the observa- 
tion of general health conditions among children, and 
three others (ix, x, and xi) for the purpose of acquaint- 
ing them with the most important facts regarding those 
transmissible diseases which concern the school. Three 
additional chapters (xv, xvi, and xvn) are devoted to 
suggestions for the teaching of hygiene in the grades, 
and another chapter (xvm) discusses health conditions 
among teachers. It will be seen, therefore, that the 
book has been planned primarily for the use of the 
grade teacher, and with her needs especially in view, 
though it is hoped that it may also serve as a handbook 
for the guidance of superintendents, school nurses, and 
boards of education. 

It is seldom that we have presented, by authors of 
such extended practical experience and large technical 
knowledge, a book on such a technical subject written 
in such simple language and presented in so attractive 
a manner. 

Stanford University, Cal., 
May 6, 1914. 



CONTENTS 



CHAPTER I 

Social Responsibility for the Health of School 

Children 1 

The spread of school medical work. Physical defects 
among school children. Parental guardianship of children's 
health not sufficient. The responsibility of society. The rela- 
tion of the school medical service to private medical practice. 
Other functions of school health departments. The reaction 
of school health work upon the home. Opposition to school 
medical work. References. 

CHAPTER II 

The Scope and Administration of Health Super- 
vision 15 

Stages in the development of school health work. The 
divisions of educational hygiene. Outline of the scope, 
procedure, and administration of medical supervision. 
Method of control. Division of power. Records. Schools 
and publicity. References. 

CHAPTER HI 

Plans for Organization for Health Work . . 37 

State versus local control. Examples of state departments. 
City organization of school health supervision. Plan (1): 
Physician and nurses. The cost of health supervision by 
Plan (1). 

CHAPTER IV 

The School Nurse: including Suggestions for 

Health Supervision by the "Nurse Alone" Plan 48 

Spread of school nursing. Nurses necessary for follow-up 
work. School nurses reduce absence. Other functions of the 



CONTENTS 

school nurse. Influence of school nurses upon the home. 
Number needed. Equipment needed by school nurses. A 
plan for the health supervision of schools by nurses alone. 
Selected references. 



CHAPTER V 

The Health Grading of School : Children by 

Teachers 62 

The general importance of the teacher's cooperation. 
Teachers versus physicians. An outline for the health 
grading of school children by teachers. Health survey. Sug- 
gestions for using the outline for health grading. The signifi- 
cance of the answers to the questions. Some results secured 
by the outline for the health grading of school children. 
References. 

CHAPTER VI 

A Demonstration Clinic for Instruction in the 

Observation of Defects 90 

Verbatim report of a demonstration clinic. A summary of 
clinics held at sixteen cities. 



CHAPTER VII 

The School Medical Clinic 109 

Difficulty of getting results from medical inspection. 
What the school clinic is. Typical school medical clinics of 
England. Cost, equipment and management. Why free 
clinics are necessary. The opposition to free school clinics. 
To protect the health of children is a social obligation. 
Summary. References. 

CHAPTER VIII 

School Dentistry 125 

Historical. Dental clinics should be free. Preventing 
dental decay. References. 



CONTENTS xi 

CHAPTER EX 

Transmissible Diseases 133 

The school as a factor in the spread of contagious diseases. 
The school as a means of controlling contagious diseases. 
Newer ideas about modes of infection. Danger of the com- 
mon cup, common towel, etc. Air not a common source of 
infection. Isolation of "carriers" versus school closing. 
Ages at which transmissible diseases most often occur. 

CHAPTER X 

Transmissible Diseases (Continued) 148 

Measles. Scarlet fever. Diphtheria. Whooping-cough. 
Mumps. Chickenpox. Smallpox. 

CHAPTER XI 

Transmissible Diseases (Concluded) 175 

Tuberculosis. Hookworm disease. Poliomyelitis (Infan- 
tile paralysis). Epidemic Meningitis. Contagious eye 
diseases. Contagious diseases of the skin. General sum- 
mary. Selected references. 

CHAPTER XII 

Open-Air Schools 198 

Recent spread. Program. Results. Pedagogical results. 
References. 

CHAPTER XIII 

School Housekeeping • . . . . 209 

School dust and its dangers. Prevention of dust by means 
of floor oils. Method of cleaning. Other ways of preventing 
dust. Standards of cleanliness. Professional training for 
janitors. References. 



xii CONTENTS 



CHAPTER XIV 

The Teaching of Hygiene: The First Six Grades 221 

Inculcating health habits. Health instruction in the first 
five grades. Personal hygiene inspection by teacher and 
pupils. Inculcating food habits. Vital topics of hygiene 
study for grades three to five. Teaching hygiene in the 
sixth grade. Hygiene lessons dramatized. Outline of 
scheme for teaching hygiene in the sixth grade. 



CHAPTER XV 

The Teaching of Hygiene: Seventh and Eighth 

Grades 236 

Early instruction must deal with the concrete. Focus 
attention upon health rather than upon disease. Practical 
instruction in bacteriology for the seventh and eighth grades. 
Teaching hygiene by means of "sanitary surveys." Helps 
for the teaching of hygiene in the grades. 

CHAPTER XVI 

The Teaching of Hygiene: Education with Ref- 
erence to Sex 252 

The problem. Need of safeguarding school children. The 
school's relation to sex-education. Special considerations 
relating to sex education. Methods and content of instruc- 
tion by stages. Divided responsibility of the home and 
school in sex-education. Selected references. 

CHAPTER XVII 

The Teacher's Health 270 

Mortality rate and physical morbidity. Premature super- 
annuation. Tuberculosis among teachers. The teacher as 
neurasthenic. Health suggestions for the teacher. The 
hygiene of character. How to prevent mental fixation. 
The responsibility of the normal school. Vocational guid- 
ance for teachers. References. 



CONTENTS xiii 



chapter xvrn 

What the World is doing for the Health of 
School Children 285 

England. Germany. France. Switzerland. Sweden. Den- 
mark. Norway. Scotland. Ireland. Canada. Australia. 
Japan. Other countries. The United States. Conclusion. 
References. 

APPENDIX 

School Health Organization in Various Cities of 
,the United States 305 

Milwaukee. Minneapolis. Philadelphia. Oakland. New 
York. 

Suggestions for a Teacher's Private Library in 
School Hygiene 315 

GLOSSARY 317 

INDEX 319 

Note: The authorship of the chapters of this book is as follows: 
Dr. Hoag — Chapters III, V, VI, IX, X, XI, XIV, and XV. 
Prof. Terman — Chapters I, II, IV, VII, VIII, XII, XIII, XVI, 
XVII, and XVHI. 



p 

•N 



/ 



LIST OF ILLUSTRATIONS 



Facing 
School nurse recording pulse and temperature in an open-air 
class _, . . 54 

^Testing vision 96 

Adenoids . . . 98^ 

Crossed eye and obstructed breathing 99 

f Testing hearing . 100 ^' 

Teeth examination . . . . . . . . . . . 101 v 

Chronological and physiological age 106 / 

A school dental clinic in Rochester, New York .... 130 / 

Crooked teeth 131 \/ 

Open-air schools 200 »/ 

An open-air class in mid-winter, Chicago ...... 206 ■,/ 

Chicago open-air classes 207 " 

The Muroscroll 216 



v 



LIST OF FIGURES 



1. Percentage of recommendations acted on in Philadelphia . 50 

2. Teeth diagram 79 

3. Weekly average of deaths from measles in London, England 134 

4. Curve showing number of cases of diphtheria in Halle, Ger- 

many 135 

5. Curve indicating average seasonal occurrence of all chil- 

dren's diseases in the Berkeley schools 145 

6. Showing the average weekly gain or loss in weight of children 

attending the Bradford Open-Air School .... 200 

7. Haemoglobin tests, Providence Open- Air School . . . 202 

8. Curves showing changes in haemoglobin during school year . 203 



HEALTH WOKK IN THE 
SCHOOLS 

CHAPTER I 

SOCIAL RESPONSIBILITY FOR THE HEALTH OF 
SCHOOL CHILDREN 

The spread of school medical work 

The health supervision of schools is not a passing 
fad. The conservation of the child is a problem which, 
like that of world peace, is bound to take possession of 
the minds of all humanitarian people. To the ethical 
principle of humanitarianism is added the stern counsel 
of biological laws, which teach us that an elaborate 
scheme of mental culture which proceeds without 
regard to the needs of the body is but a house built 
upon the sands. 

It is significant for the future of the movement that 
with minor exceptions all civilized countries have 
almost simultaneously taken it up. Its universal de- 
velopment is inevitable. Progress has been remarkably 
uniform in different countries, though naturally there 
are some differences in the details of procedure and in 
the points of emphasis. Germany has forged ahead 
with her dental clinics and open-air schools; France, 
with her school lunches and vacation colonies; while 
England has set the whole world an example in the 



2 HEALTH WORK IN THE SCHOOLS 

earnest way in which she has undertaken to ameliorate 
the evils which medical inspection of schools has 
revealed. Our own country, on the whole, is behind 
most of the nations of Europe in the practice of school 
hygiene, but is making progress rapidly. But the 
doctor has not been brought into the school without 
opposition, and it is therefore desirable to inquire 
further into the justification for this new assumption 
of responsibility on the part of organized society. 

Physical defects among school children 

Serious defects of eyes, ears, nose, throat, lungs, 
teeth, glands, nutrition, heart action, nervous co- 
ordination, and mentality have been discovered with 
surprising frequency wherever they have been looked 
for. Statistics on these matters have been so indefi- 
nitely extended and (when we make allowance for cer- 
tain differences in procedure) have given such uniform 
results, that we can safely say that in any school sys- 
tem, no matter where it may be located or to what 
social classes its patrons belong, from 50 to 75 per cent 
of its pupils are suffering from one or more physical 
defects serious enough to require skilled attention. 1 

While it is not claimed that all this defectiveness is 
produced by the school, some of it undoubtedly is, and 
in the case of still other pupils the school is at least a 
partial cause. At any rate, it is well known that defec- 
tive pupils are present in the schools in large numbers, 

1 Lewis M. Terman, The Hygiene of the School Child, chapter I. 
Houghton Mifflin Co., 1914. 



SOCIAL RESPONSIBILITY 3 

and that the defects are often unfavorable to a normal 
physical and mental development. Although many of 
the defects are curable or preventable, as a rule even 
intelligent parents and teachers either do not observe 
them or else they underestimate their seriousness. 

Parental guardianship of children's health not 
sufficient 

If all parents were wise in regard to health matters, 
it would not be so necessary for schools to make a 
special study of the physical conditions of the children 
entrusted to their care. All that could then be fairly 
required would be the guaranty of a healthful school 
environment, including such things as good ventila- 
tion, correct methods of lighting and heating, sanitary 
plumbing, the control of contagious diseases, frequent 
recesses, sufficient physical training, and the proper 
sort of health instruction. But it is a fact and not a 
theory that not all parents possess the special knowl- 
edge which is necessary for the hygienic supervision of 
physical and mental development. Even intelligent 
parents may be unable to detect the early symptoms of 
physical disorder, just as they may be unable to decide 
upon the best methods or texts for teaching history or 
geography. They do not see the defects in their own 
children because they are used to them. Many are so 
superstitious as to prefer to treat adenoids by sugges- 
tion, others so ignorant as to interpret pediculosis 
capitis as a sign of good health. Plainly, therefore, it 
becomes the duty of the school department to furnish 



4 HEALTH WORK IN THE SCHOOLS 

not only a healthful school environment, but also a 
health guardianship over its pupils. 

The responsibility of society 

The children of to-day must be viewed as the raw 
S material of a new State; the schools as the nursery of 
the Nation. To conserve this raw material is as logical 
a function of the State as to conserve the natural 
resources of coal, iron, and water power. To investi- 
gate exhaustively the evils which exist and to remedy 
all that may be remedied without transgressing unduly 
upon the jealous precincts of parental responsibility is 
a plain matter of duty. Theoretically, it matters little 
how the State performs this duty, whether by a house- 
to-house census of the children, or in some other way. 
Practically, however, there is no effective or conven- 
ient way except to do the work in connection with the 
public schools. In many of our best towns and cities 
the people themselves are demanding such supervision 
on the principle that it is one of the important func- 
tions of the public school system. 

The argument that the health supervision of schools 
invades the rights of the home has exactly the same 
value as the corresponding argument against com- 
pulsory school attendance and prescribed courses of 
study. The school does not claim anything more than 
the right to make an examination of the child's physi- 
cal and mental condition in order that the work of the 
school may be properly adjusted to his health and 
growth needs, and, further, to notify and advise 



SOCIAL RESPONSIBILITY 5 

parents regarding such defects as are found to exist. 
This is not an unwarranted assumption of power. The 
responsibility for remedial action is left entirely with 
parents. The school has not undertaken forcibly to 
subject children to surgical operations, nor is there at 
present any legal method of compelling parents to per- 
form their duty in this respect. We can invoke the law 
for wanton neglect of a broken bone, but there is 
no way to punish the neglect of discharging ears, 
adenoids, or astigmatism, any one of which may 
prove more serious in the long run than a fractured 
bone. 

It is interesting to conjecture how far present prac- 
tice in this respect is likely to be modified. Compulsory 
public education itself is so recent that only a few dec- / 
ades ago it was considered by a majority of people as a 
species of meddlesome paternalism. According to the 
old conception the child was the parents' child; if they 
questioned the value of an education there was no 
recourse in the child's behalf. There are a million or 
more illiterate adults in the United States to-day 
who are victims of this mistaken social theory. The 
theory, happily, has been discarded. We now know 
that the interests of society demand an elaborate 
scheme of educational processes under social control. 
Some time we shall understand, just as clearly, that 
the child's physical growth also stands in need of more 
expert supervision than the average parent is capable 
of exercising. 



6 HEALTH WORK IN THE SCHOOLS 

The relation of the school medical service to private 
medical practice 

It is sometimes contended that all medical work 
should be left in the hands of the family doctor, and 
that the employment of school physicians is both an 
^ impertinence and a needless expense. The practicing 
physician himself often takes this stand, just as for- 
merly private teachers resented the intrusion into their 
domain of teachers who were paid at public expense. 
The two situations are strikingly similar. There were 
private schools which afforded excellent educational 
opportunities, but unfortunately they did not reach 
all the people and they were excessively expensive. 
Similarly there are families who know enough about 
health and the causes which are likely to undermine 
it to seek the frequent advice of high-priced, skill- 
ful physicians. On the other hand, a large majority of 
families can hardly be said to have a family physician, 
and when they do his function seldom goes beyond the 
treatment of acute disease or physical injury. Under 
present conditions the family doctor institution hardly 
touches the rich field of preventive medicine with 
which it is the business of the school physician to deal. 
In the vast majority of cases, if the child's physical 
needs receive no expert oversight in the school, they 
will receive no expert attention at all. 

It is, therefore, not at all a question of relieving the 
family physician of any of the functions he has been 
accustomed to exercise, but of doing the work he has 



SOCIAL RESPONSIBILITY 7 

left undone. The practicing physician is not always 
present when needed. As a rule he docs not appear on 
the scene until an emergency occurs. He has no com- 
mission to go out in quest of disease. He has little op- 
portunity so to order the lives of his clients that they 
will escape emergencies. We refuse to pay him except 
to cure our diseases; it is unfair as well as absurd, 
therefore, to expect that his chief interest will be in the 
prevention of disease. The wonder is that the disparity 
between the physician's interest in disease and his in- 
terest in health is not greater. It is to the credit of the 
profession that the better class of practicing physicians 
almost unanimously indorse the work the schools have 
undertaken in child hygiene. 

Other functions of school health departments 

Apart from its contribution to national vitality, the 
health supervision of schools is entirely justified by its 
influence upon the efficiency of the school itself. For 
one thing, it appreciably affects regularity of attend- 
ance, which, as Ayres has shown, is one of the im- 
portant factors in retardation. It does this by elimi- 
nating some of the causes of illness, and by treating in 
the school certain parasitic diseases and other slight 
ailments which otherwise would require exclusion. 
Ringworm and pediculosis, especially, have in the past 
caused a great deal of needless irregularity of attend- 
ance. Chronic physical defects, particularly of breath- 
ing and of nutrition, have a retarding effect on school 
progress, even when they are not of such a nature as to 



8 HEALTH WORK IN THE SCHOOLS 

cause absence. To the extent that health supervision 
of schools is successful in securing the medical or sur- 
gical treatment of defects, or in ameliorating environ- 
mental conditions in the home, it cannot fail to con- 
tribute to the solution of the retardation question. 

In the prevention of epidemics the school depart- 
ment of health renders invaluable assistance to the 
local non-educational board of health. The latter is 
usually given authoritative control in such matters as 
closing the schools, granting permits to return after 
illness, etc., but the closer contact of the school health 
officer with the pupils often enables him to sound the 
alarm and in many ways to become a necessary ally in 
preventing the spread of infectious diseases. 

Not the least important function of the school 
health department is that of cooperation with the 
school architect and sanitary engineers. Of the mil- 
lions of dollars expended annually in the United 
States for school buildings, a large part, from the point 
of view of school hygiene, must be considered as 
almost wasted. School buildings erected earlier than 
twenty years ago belong usually to discredited types 
of architecture, and are being replaced rapidly by new 
and still more expensive plants. Unless these embody 
the very best ideas in sanitation and hygiene, they, 
too, will soon have to be replaced. There is no reason 
why the better class of school buildings erected to-day 
should not be well preserved and for the most part 
hygienic in the year 2000. It would be hard to over- 
estimate the injury that may be wrought in three 



SOCIAL RESPONSIBILITY 9 

quarters of a century by a poorly lighted, ill- ventilated, 
or unsanitary school building of twenty-five rooms. 
Within that time many thousands of children will have 
been subjected to its unwholesome influence. The re- 
sulting sickness, ill health, and death would appall us, 
if it were possible to estimate it. 

The health department will also give immediate 
returns in the hygienic supervision of school activities. 
Competitive athletics, for example, are always danger- 
ous without such control, particularly below the col- 
lege age. Likewise the hygiene of instruction presents 
a promising field of research that can best be carried on 
by official investigation supported by the school itself. 
There is hardly a limit to the number of hygiene re- 
searches which it would be feasible for the school to 
undertake. 

Furthermore, the department of health would give 
valuable assistance to the teaching corps in hygiene 
teaching. At present hygiene is one of the least taught, i 
and probably also the worst taught, of all the branches 
of the curriculum. This is largely because the teachers 
themselves have been poorly instructed in the subject., 
The work of the health department in this respect is 
twofold: (1) It will give the teachers themselves sys- 
tematic instruction in the hygiene of physical and 
mental development, so that they may cooperate in- 
telligently with the work of the department; and (2) it 
will aid the teachers in the choice of subject-matter and 
in the methods of presenting hygiene lessons in the 
schools. 



10 HEALTH WORK IN THE SCHOOLS 

Finally, health supervision in the schools will con- 
tribute to the conservation of the teacher's health. 
This has been fully presented in chapter xvm, and 
need not be dwelt upon here. 

The reaction of school health work upon the home 

But, supposing that all defects have been discovered, 
and that school life goes on without aches and pains, 
must we go all over the work next year and the next, 
forever? Is the social mill to go on, indefinitely, grind- 
ing out diseased and crippled children by the thou- 
sands? The most hopeful approach to this problem lies 
in the schools themselves. By all means let us remedy 
defects when they exist, but, in addition, let us en- 
deavor to prevent defects from occurring. The school 
must investigate the home conditions of defective 
pupils. It must know more of the child's habits, what 
time he goes to bed, how long he sleeps, how much he 
works, how much he studies at home, what he eats, 
what he drinks, where and under what conditions he 
sleeps, and what the home environment is in every 
particular that concerns the child's health. If we read 
the lesson of the health index aright, it means not only 
sick school children, but sick school buildings and sick 
homes as well. The health of the child reflects the 
health of the community in which he lives. 

The surest means of increasing community health 
are: (1) by increasing the health of the child through 
improved school conditions, and by attention to his 
physical defects; (2) by teaching the child sensible, ap- 



SOCIAL RESPONSIBILITY 11 

plicable health lessons; (3) by carrying the influences of 
this health improvement and health instruction into 
the home. 

The public school has not fulfilled its duty when the 
child alone is educated within its walls. The school 
must be the educational center, the social center, and 
the hygienic center of the community in which it is 
located, — a hub from which will radiate influences 
for social betterment in many lines. 

Opposition to school medical work 

Thus far the opposition to health supervision in the 
schools comes from three chief sources. One of these is 
the misconception as to the purpose of the work which 
is likely to be entertained by the more ignorant people 
of a school community. At first such people are likely 
to become panic-stricken with the foolish notion that 
their children may be subjected to some strange kind 
of violence, forcible surgical attention, hypnotism, etc. 
As the school health officer becomes a more familiar 
figure about the school premises, and as his kindly in- 
terest in the children becomes known, this fear always 
disappears. 

The two other sources of opposition are harder to 
eradicate, because founded on prejudice rather than 
ignorance. These are the Christian Scientists, and the 
League for Medical Freedom. 

The tenets of the former are so well known that they 
need not be discussed here. It is well to note, however, 
that the attitude of Christian Scientists toward school 



12 HEALTH WORK IN THE SCHOOLS 

health work is not always unfriendly where the purely 
advisory capacity of the school doctor is understood. 
On the other hand, where the school authorities, in 
their communications and notices to parents, are at 
all insistent in their efforts to bring about the correc- 
tion of defects, the enmity of this religious sect is likely 
to be aroused. Notwithstanding certain hygienic 
principles in Christian Science, its sweeping warfare 
against medicine must be viewed as the conflict of an 
absurd superstition with the welfare of the State and 
its children. Superstition has had to yield to quaran- 
tines and to state laws which punish parental neglect 
in case of acute and immediately dangerous diseases. 
Here, also, it will have to adjust itself as best it can to 
the march of science, which, at last, is beginning to 
question the right of either parental or religious au- 
thority to interfere with the health or safety of the 
child. 

The League for Medical Freedom is a less worthy, 
but a more active and dangerous, opponent of child 
hygiene measures. This is a recently founded and 
vigorous organization composed largely of "sectarian" 
physicians, quacks, and patent-medicine vendors, 
whose main purpose seems to be to oppose all social 
restraints on medical practice and to preserve the 
divine right of all kinds of practitioners, regular and 
irregular, to prey upon the gullibility of the people. In 
the short time since it was organized, it has in several 
cases successfully opposed the extension of school 
medical inspection, and has defeated progressive legis- 



SOCIAL RESPONSIBILITY 13 

lation on matters relating to hygiene and medical 
practice generally. 

Its methods are always and everywhere the same — 
to prejudice the minds of those not alive to the real 
issue by the cry of "medical tyranny," "political doc- 
tors," "sacred rights of the family," etc. Teachers will 
not be deceived by catchwords of this sort, enlisted in 
the cause of the patent-medicine industry and quack 
schools of "healing." Teachers are intelligent enough 
to scent the insincerity in the argument that medical 
inspection is being fostered for the special benefit of a 
particular "school" of medicine, — the allopathic 
versus the hydropathic, homoeopathic, osteopathic, 
naturopathic, etc. It is well for teachers to understand 
that real medical science is not torn asunder by sepa- 
rate schools, any more than is the science of chemistry 
or physics. There is only medical science on the one 
hand, and quackery and superstition on the other. 

All such opposition will gradually be dissipated, or 
at least silenced. Medical inspection, enlarged to in- 
clude all phases of school hygiene, will soon be looked 
upon as a mere matter of course, — the logical and 
necessary correlate of compulsory education. 

REFERENCES 

(The most important references are indicated by a *) 

1. Allen, W. H.: "A Broader Motive for School Hygiene." Atlan- 
tic Monthly, June, 1908. 

2. Blan, Louis: " Are we taking Proper Care of the Health of our 
Children?" Ped. Sem., 1912, pp. 220-27. 

3. Burnham, W. II.: "Health Inspection in the Schools." Ped. 
Sem., 1900, pp. 70-94. 



14 HEALTH WORK IN THE SCHOOLS 

*4. Dresslar, F. B. : " The Duty of the State in the Medical Inspec- 
tion of Schools." Bull. A96, U.S. Bur. of Ed., 1912. 

5. Fisher, Irving : " Public Responsibility for the Health of Infants 
and Children." Fed. Sem., 1909, pp. 395-402. 

6. Gorst, Sir John E.: The Children of the Nation. (Chapter iv, 
pp. 50-66.) 

*7. Gulick and Ayres: Medical Inspection of Schools. 1913, pp. 224. 
(Chapter i.) 

8. Gulick, Luther H.: "Constructive Community and Personal 
Hygiene." Science, 1910, pp. 801-10. 

9. Cronin, John J.: "The Doctor in the Public School." Review of 
Reviews, 1907, pp. 433-40. 

10. Forsyth, David: Children in Health and Disease. 1909, pp. 360. 

(Chapter vi.) 
*11. Hall, G. Stanley: "The Medical Profession and Children." 

Red. Sem., 1908. 
*12. Hogarth, A. H.: Medical Inspection of Schools. 1909, pp. 360. 

(Chapters in to vin, inclusive.) 
*13. Moore, Benjamin: The Dawn of the Health Age. Liverpool, 

1910, pp. 204. 
14. Osier, Dr. William: "Medical and Hygiene Inspection of 

Schools." Rept. Inter. Cong. Sch. Hyg., 1907, pp. 465-68. 
*15. Terman, Lewis M.: The Hygiene of the School Child. 1913. 

(Chapter i.) 
, See Collier s Weekly, June 3, 1911, for an expose of the " League 

for Medical Freedom." 

See all standard works on school hygiene or medical inspection 

of schools. 



CHAPTER II 

THE SCOPE AND ADMINISTRATION OF 
HEALTH SUPERVISION 

Stages in the development of school health work 

The health supervision of schools presents three 
clearly defined stages in its development : — 

(1) Its original purpose in almost every case was the 
detection of contagious disease. The work was merely 
an extension of that of the local board of health, and 
was designed to protect the community from epidem- 
ics. The value of such inspection immediately became 
evident. 

(2) The second stage is represented by the extension 
of the scope of the work to include examinations for 
non-contagious physical defects. The early surveys 
of the Danish and Swedish commissions had dem- 
onstrated an enormous prevalence of defectiveness 
among supposedly normal children of both sexes and 
of all ages and classes. It was discovered that many of 
these defects have a bearing upon the child's school 
progress, and upon his physical development. It was 
observed, moreover, that many of them are easily 
curable or removable. About two hundred cities in the 
United States, mostly the larger ones, have under- 
taken to give their school children complete examina- 
tions for all kinds of physical defectiveness. 



16 HEALTH WORK IN THE SCHOOLS 

(3) The third stage passes beyond "medical inspec- 
tion," as such, and becomes a distinct field of preven- 
tive medicine. A suitable name for it is "Health and 
Development Supervision." Its keynote is the cultiva- 
tion of health and the prevention of defectiveness by 
the hygienic supervision of all the, school activities. 

This phase of child hygiene, the most important of 
all, is just in its beginning. Health supervision has 
been too narrowly conceived, but we are coming to 
realize that almost everything which contributes to 
the conservation of the child belongs within its scope. 
The schools, instead of causing sickness and defective- 
ness, must be made to preserve the child from many 
kinds of morbidity, repair his already existing defects, 
and combat his hereditary predisposition to illness 
and the unfavorable conditions of his social environ- 
ment. 

In order to prosecute the work intelligently hun- 
dreds of researches will have to be made; researches to 
which the public schools must be freely thrown open, 
and for the support of which public funds should be 
appropriated. Out of the data from such investiga- 
tions there will rise, gradually, a new science of educa- 
tional hygiene which will go as far beyond the usual 
poverty-stricken courses in "school hygiene" as medi- 
cal science now transcends the teachings of the eight- 
eenth-century medical school. 1 

The broad scope of educational hygiene is made 
clear in the following outline, which is a modifica- 
1 See Popular Science Monthly, 1912, pp. 289-97. 



SCOPE AND ADMINISTRATION 17 

tion of the comprehensive suggestions of Louis W. 
Rapeer. 1 

The Divisions of Educational Hygiene 

I. School sanitation. 

A. School sites, hygienic aspects. 

B. School arelfftecture, hygienic aspects. 

C. Ventilation and humidification. 

D. Lighting. 

E. Heating. 

F. Drinking-water and fountains. 

G. School baths. 
H. School cleaning. 

I. School toilets. 
J. Seating. 
K. Decoration. 
L. The standard schoolroom. 
M. Janitor service. 

n. Physical education. 

A. Playgrounds and play. 

B. Athletics and "leagues." 

C. Physical training. 

D. Correctional exercises. 

E. Posture. 
.F. Recreation. 

G. School excursions, "tramps." 

H. Physical development examinations. 

I. Gymnasiums and gymnastics. 

J. Swimming and bathing. 
K. Medical gymastics. 
L. Social center work for adults. 

III. Health teaching. 

A. Choice of hygiene texts. 

B. Health instruction topics. 

1 The authors are indebted to Dr. Louis W. Rapeer for permission 
to include this valuable outline in the present volume. No one else 
has made such a thorough study of efficiency in school-health serv- 
ice as Dr. Rapeer. 



18 HEALTH WORK IN THE SCHOOLS 

C. Health habits. 

D. Public and personal hygiene. 

E. Health education of parents. 

F. Feeding and clothing of children. 

G. Health education of teachers. 

H. Home hygiene, in domestic science. 

I. Industrial hygiene, in industrial work. 

J. First aid and avoidance of accidents. 

K. Talks by doctors, nurses, and specialists. 

L. Pupil's cooperation in medical supervision. 

M. Health leaflets. 

IV. The hygiene of instruction and of mental development. 

A. Fatigue. 

B. School program. 

C. Home study. 

D. Examinations. 

E. Type of books. 

F. Motor aspects of teaching. 

G. Cheerfulness and calmness. 
H. Part time or whole time. 

I. Vacations and their influence. 

J. Teaching through play. 

K. Attention and inter-recitation recreation. 

L. Preventing pathological conditions. 
M. The hygiene of discipline. 

N. The hygiene of classification, promotion, and 
gradation. 

O. The hygiene of mentally exceptional children; the 
nervous, the feeble-minded, etc. 

P. The hygiene of the learning process, habit forma- 
tion, etc. 

V. Medical supervision. 

Each of the above divisions should have its special 
texts, and its special courses in teacher's colleges and 
normal schools. Space is lacking to show in detail the 
contents, aim, and procedure for each division, but 



SCOPE AND ADMINISTRATION 19 

this will be done for Division V, Medical Supervision. 
The following outline, based upon Rapeer's conclusions 
from his valuable comparative study of medical su- 
pervision in twenty-five American cities, reveals the 
scope and procedure for one of the five divisions given 
above: — 

Outline of the Scope, Procedure and Administration 
of Medical Supervision 

A. Officials. 

1 . General director of the department of hygiene. 

2. Medical examiners. 

3. Nurses. 

4. Oculists, dentists and surgeons at school clinics and 

dispensaries. 

5. Teachers, principals, and superintendents. 

6. Physical-training teachers. 

7. Board of health. 

8. Sanitary inspectors. 

9. Health lecturers. 

B. Phases of work of medical supervision. 

1. Preliminary working together of all doctors and 
nurses, with teachers present as much as possible 
for standardization. 

2. Inspections. 

a. September room inspection of all pupils. 

b. Occasional room inspection by nurses. 

c. Individual inspection by teachers and nurses, 
teachers to refer suspicious cases with help of 
symptom chart. Nurse to inspect, also, all 
pupils absent for three or more days, and 
entering pupils. Doctor to make individual 
inspection of urgent cases. 

d. Home-hygiene inspection by nurses. Re- 
corded on pupil's health-record card. 

e. Sanitary inspection of school. By superin- 
tendent of school or representative: doctor, 



20 HEALTH WORK IN THE SCHOOLS 

nurse, principal, business manager, or sanitary 
inspector. 

3. Examinations — Complete physical, annually, for 
pupils. 

a. Medical — only such phases by the doctor as 
the nurse cannot do well. 

6. "Vision, hearing, teeth, scalp, skin, — by the 
nurse. 

c. Height, weight, chest-expansion, and other 
measurements, if required — by nurse, physi- 
cal trainers, or principals. 

4. Cure and correction. 

a. Treatments by the home through school 
advice and family physicians. 

b. Treatments by school nurses and clinics. 

c. Follow-up work in getting or keeping up treat- 
ment. 

d. Prescriptions for simple, common ailments, so 
far as safe, in the language of the people. 

e. Getting cooperation of dispensaries, boards of 
health, etc. 

/. Testing efficiency by cures and improvements. 
g. Health-budget exhibits, and other means of 
health education. 

5. Central office where parents may bring children for 
special examinations and for consultation, includ- 
ing psychological tests. 

6. Prevention. 

a. Good ventilation, fresh-air or open-air rooms 
or schools. 

b. Summer inspection by nurses, at playgrounds 
and summer schools. 

c. Special inspections, to prevent epidemics. 

d. Improved instruction of pupils and parents in 
hygiene. 

e. Cooperation with health and recreation agen- 
cies. 

/. Daily inspection, by nurses. 
g. Testing efficiency by decrease of ailments and 
defects. 



SCOPE AND ADMINISTRATION 21 

h. Efficient supervision of doctors and nurses. 
i. Limiting medical inspectors largely to examin- 
ations. 
j. Coordinating all phases of educational hygiene. 
k. Continued home-hygiene inspection. 

C. Records and reports. 

1. Individual, cumulative health-record card. 

a. The central instrument of medical supervi- 
sion, as nurse is the central agent. 

6. Should provide for entire health record, includ- 
ing inspections, examinations, and records of 
cures and improvements. 

c. Should have the good features of the Cleve- 
land, Ohio, the Meriden, Connecticut, and Dr. 
W. S. Cornell's cards (and, perhaps, those of 
the New York City card for both health and 
scholastic record). 

d. May be kept in the classrooms for teachers' 
constant reference and carried by pupils to 
inspection or examination. 

e. Doctor's findings on the twenty or more exam- 
ination cards daily should be left for the nurse 
to report, before cards are returned, to the 
rooms. Doctor may be relieved of most clerical 
work, if results are supervised, thus saving 
time. 

/. To distinguish, nurse should make records on 

cards in red ink, doctor in black. 
g. State or national cards should be adopted. 

2. Nurse's daily or weekly report. 

a. The best type is probably that of the weekly 
report of the nurses in the Philadelphia 
schools. 

b. Nurse reports number and results of doctor's 
examinations, as well as her own. 

c. Reports should be summarized weekly, and 
printed in newspapers. 

d. A standard classification of school ailments 
should be used. 

e. Simplest classification is, infectious and non- 



22 HEALTH WORK IN THE SCHOOLS 

infectious, using common names in alphabetical 
order. The former may be divided into para- 
sitic and infectious diseases, the latter into 
physical defects and common ailments. Gen- 
eral divisions, such as communicable and non- 
communicable diseases, are desirable. 

3. Annual report to the people. 

a. Should be detailed, and yet comprehensible to 
the public. 

b. It should show how many cases were found, 
how many cured, improved, found not needing 
treatment by family physician, and by what 
agencies cared for. The number, not cured, 
treated, or improved, is a most necessary part 
of efficient reporting. Adequate reporting in 
this field has not been worked out by any 
city. 

4. Other records, notices, reports, exclusions, etc., 
need be little different from those in vogue. (Rec- 
ords should lead to a frequent health invoice.) 

D. Standardization. 

1. Examinations. 

a. Medical, by the doctor (medical examiner) if 
there is one. 

X. Number, 7 to 10 an hour, say twenty in a 
two-hour day when there are no excep- 
tional cases, or about one hundred a 
week. 

Y. Depending upon the district and the 
amount of consultation by nurse and in- 
dividual inspection of referred cases, the 
doctor can examine medically from 1500 
to 2000 pupils in the 180 days of the usual 
school year. (Minimum.) 

Z. In the nurse-alone plan, one nurse can 
examine from 800 to 1200 pupils in the 
year and do her other work of home 
visiting and inspection, varying greatly 
with nurses and communities. 

b. Scholastic or anthropological. 



SCOPE AND ADMINISTRATION 23 

X. Vision tests, about three minutes each. 
Snellen's charts. Vision less than 
twenty- twenty referred only when 
there are bad symptoms of eye-strain, 
otherwise twenty - forty. Strabismus 
(cross-eye) should always be referred for 
treatment. 

Y. Hearing tests, about two minutes each — 
twenty an hour, at least. By nurse or 
physical trainer. Stop-watch and whis- 
per tests. Common sense about the only 
standard yet. 

Z. Height, weight, and chest-expansion 
measurements, if required, about three 
minutes each. Of little value as usually 
taken. Rarely used, even when well 
taken with pupils stripped. 

2. Inspections. 

a. September room inspections, — about forty 
an hour, nurse and doctor working in separate 
rooms with help of teachers. 

6. Nurse and doctor should be conservative 
about referring cases and excluding pupils, 
even in case of threatened epidemic. 

c. Sanitary inspection of school, standardized by 
a special report card such as used by the 
Philadelphia Board of Health (devised by the 
Bureau of Municipal Research). 

d. Nurses and doctors should be given schools in 
groups, or along good lines of travel. 

3. Efficient supervision, and occasional working to- 
gether on a number of referred cases by all doctors 
and nurses, highly desirable for purpose of stand- 
ardization. 

E. Expenditures. 

1. For nurse: five and a half days a week (8.45 to 5 
each school day), with the responsibility of inspec- 
tion, not less than $70 a month, preferably for 
twelve months. 

2. For doctor: two hours spent in a single school each 



24 HEALTH WORK IN THE SCHOOLS 

day, making a reasonable number of careful medi- 
cal examinations, forty hours a month, about $60 
to $80 a month for ten months. Where more is paid 
it is a question whether it would not be better to use 
the money for a good nurse on full time. Physical 
examinations cannot be carried on more than two 
or three hours a day, because of the physical strain. 
Neither can physicians be taken for long from their 
regular practice each day. To employ all for full 
time is out of the question. Diminishing returns 
bring in the nurse, often more competent for the 
simple school troubles to be referred to parents and 
family physicians, than is the school doctor. 

3. Supervisor of the Department of Hygiene : $3000 to 
$4000 a year, for full time. 

4. Supplies : depending upon conditions, although cer- 
tain standard supplies can be designated. Newark, 
New Jersey, has a good list. This phase of the work 
varies greatly in different cities. 

5. Free treatment: Amount of free treatment is rapidly 
increasing in the larger cities. While using care, 
this work must be greatly extended. 

School medical inspection still suffers from lack of 
standards. Too often a narrow view prevails regarding 
the opportunities and responsibilities which the work 
involves. As stated by Rapeer, "the public demand 
for more attention to the health of school children has 
often been met by such temporizing sedatives as the 
hiring of some doctors to look into the school buildings 
occasionally when they have time; having manufac- 
turing companies send in a few samples of sanitary 
drinking-fountains or adjustable desks; or permitting 
the park department to station a young woman with a 
see-saw and a swing on some school-yard 'playground' 
during the summer." 



SCOPE AND ADMINISTRATION 25 

It is with the hope of broadening the scope of health 
work in the schools and contributing to the standardi- 
zation of its methods that the above outline has been 
presented. The authors believe that it cannot be too 
carefully studied, either by school boards, superin- 
tendents, school doctors, or teachers. 

Method of control 

This was one of the earliest questions to arise. Medi- 
cal inspection everywhere began as an extension of the 
work of the already existing board of health. However, 
the more the scope of health supervision has been ex- 
tended, the greater the tendency has been to doubt the 
wisdom of this method of control. Three leading 
objections have been made : — 

(1) The board of health is almost certain to place 
the emphasis too much on the mere prevention of 
disease. Insidious defectiveness and the causes leading 
up to it are likely to be overlooked; 

(2) The board of health is not in a position to make 
such adjustments of the educational processes as may 
be necessary to minister to the health and growth 
heeds of the pupil. Attempts to do so inevitably lead 
to conflict between the board of health and the educa- 
tional authorities, or at least to misunderstanding with 
consequent failure to cooperate; 

(3) When the work is administered by the non- 
educational machinery, the interest of the teacher is not 
so easily enlisted. The bifurcated educational aim 
which has wrought such havoc in education for hun- 



26 HEALTH WORK IN THE SCHOOLS 

dreds of years becomes through this system of divided 
responsibility more strongly intrenched than ever. 
The school looks after the child's mind, the board of 
health after its body. Everybody forgets that the 
child is a psychophysical organism and that any dual 
system of educational control is sure to violate this 
unity. 

It cannot be too often repeated that the examination 
of pupils for contagious disease is a relatively unim- 
portant part of the health supervision of schools. 
Statistics show that as a rule not more than 4 per cent 
of the pupils of a school system need to be excluded in 
one year. On the other hand, 60 per cent of the pupils 
suffer from non-contagious defects which need con- 
stantly to be taken into account by the educational 
authorities. Moreover, the physical welfare of every 
child is more or less jeopardized by the sedentary occu- 
pations, indoor life, and nervous strain of the modern 
school. The task of the school department of health is 
so to direct the educational processes that the child's 
native heritage of vigor and health may be fully at- 
tained, and his hereditary deficiencies, in so far as pos- 
sible, made good. This is an educational problem. It is 
one that is not likely to be effectively dealt with except 
through the administrative authority of the school. On 
the other hand, communities so conservative as to be 
content with the earlier type of "medical inspection" 
may very well leave the work to non-educational 
authorities. 
1 By 1911 over three fourths of the cities in the United 



SCOPE AND ADMINISTRATION 27 

States supporting health supervision had lodged the 
administration with the board of education, so that 
we may now consider educational control one of the 
standard requirements of health supervision, and the 
best guaranty of broad and effective cooperation along 
all lines of child hygiene in the schools. 

It cannot be denied, however, that in a few in- 
stances splendid work has been carried on in the 
schools by the board of health, and in a few instances 
narrow, unsatisfactory work by the educational au- 
thorities. Much depends upon the man behind the 
system. If all officers of public health had an adequate 
comprehension of the strictly educational and preven- 
tive aspects of hygiene in the schools, there would be 
less to choose in the matter of control. But as the situa- 
tion now stands, there can be no question that, gener- 
ally speaking, the health supervision of schools in this 
country ought to be conducted by educational depart- 
ments of health. There should be such departments in 
every city school system, in every county also for the 
benefit of rural and town schools, and above all a State 
department for the coordination and standardization 
of the work. 

Division of power 

Granting that such a department of health exists, 
what relations shall it sustain to the superintendent 
and to the teachers? Shall it act only in an advisory 
capacity, or may we safely charge it with a certain 
amount of administrative authority ? To be concrete, 



28 HEALTH WORK IN THE SCHOOLS 

let us suppose that the health department decides that 
a given pupil cannot safely attend school more than 
three hours per day. Let us suppose also that the 
superintendent of schools and the child's teacher dis- 
agree with this opinion. In such a case whose judg- 
ment should legally prevail? Similar questions are 
likely to arise occasionally in regard to excusing a pupil 
from gymnastics, and in regard to the segregation of 
children in special classes for open-air treatment, etc. 

It seems clear that the decisions of the department 
of health should at least not be subject to reversal by 
any other authority than the board of education or 
superintendent, and it is an open question whether the 
superintendent should have this power. School hy- 
giene is a technical field, where only expert opinion is 
reliable. Because the hygienic affairs of the school 
require expert direction, the board of education creates 
the health department for this purpose, just as it 
creates other offices for the supervision of instruction. 
The expertness of the department should, therefore, be 
respected. Deficiency of a child's blood in oxygen- 
carrying material, or a retarded condition of his 
skeletal development as indicated by the Roentgen 
rays, or an excessive predisposition to fatigue, — these 
are matters which call for expert diagnosis and expert 
treatment no less than measles or diphtheria. 

Practically, however, there ought to be few cases of 
conflict, wherever the ultimate control is vested. The 
sensible medical director will find that he must work 
through the superintendent and the teachers. If he 



SCOPE AND ADMINISTRATION 29 

conscientiously gathers his data and cautiously bases 
his recommendations upon a reliable body of ascer- 
tained fact, and if he presents these recommendations 
with reasonbale tact, there will ordinarily be no diffi- 
culty in securing favorable action on the part of super- 
intendent and board of education. On the other hand, 
if the medical director is incautious or unscientific in 
his recommendations, if he is intemperate in his con- 
demnation of current school practices, or if he meddles 
unduly with the work of instruction, the efficiency of 
his department is certain to be impaired. The school 
department of health should have no place for the man 
or woman who is temperamentally unable or unwilling 
to cooperate harmoniously with other educational 
authorities. 

Records 

The practical value of the work of the department 
of school hygiene depends intimately upon its book- 
keeping methods. Too often the methods in use fail to 
give us the information we need. The following are 
some of the faults which have helped to render the 
statistics of medical inspection confusing, contradic- 
tory, and sometimes misleading : — 

(1) Stating the absolute number of defects found 
without indicating the number of children furnishing 
them. What a community wants to know is not that 
School A has fewer defective eyes than School B, but 
the relative percentage of defective eyes in the two 
schools. 



30 HEALTH WORK IN THE SCHOOLS 

(2) We should also be informed what the percentage 
is a percentage of; whether of total enrollment, or of a 
representative portion of the enrollment, or of a por- 
tion specially selected by teachers or nurses for sus- 
pected defects. 

(3) Another common mistake is to fail to distin- 
guish between the number of examinations made and 
the number of children examined. Since many chil- 
dren receive frequent examinations, the two sets of 
facts do not even approximately correspond. 

(4) Still more serious is the failure of the general 
report to differentiate sufficiently among kinds of 
defects. The common and the extremely rare, primary 
and secondary, curable and incurable, chronic and 
temporary, the very grave and the unimportant are 
all lumped together. This leaves us without data for 
arriving at reliable conclusions as to the influence of 
the various kinds of defectiveness upon mental devel- 
opment or upon the child's school progress. In such an 
ill-considered system of records, a slightly decayed 
temporary tooth, about to be replaced by a permanent 
one, counts for just as much as an extreme case of 
myopic astigmatism or a discharging ear. Hunchbacks 
and boils are not distinguished. Again, one defect, by 
counting all its symptoms, becomes three or four. By 
one system of records a child may be accredited with 
two defects and by another system with eight or ten, 
without necessarily implying any essential difference 
in the expertness of the examinations themselves. 
Defects which are plainly temporary should be care- 



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32 HEALTH WORK IN THE SCHOOLS 

fully distinguished in reports from those which are 
chronic; likewise the curable from the incurable. 
These factors help to determine what action the 
school shall take regarding notification of parents, and 
in adapting the work of the school to the child. What 
we most want to know is how the many kinds of defec- 
tiveness are related to each other, to school progress, 
to age, and to mentality. 

(5) The pupil's individual record card is not less 
important than the general report, and is subject to 
much the same faults. It should be explicit and not 
vague. In recording a defective ear, for example, it 
should distinguish between partial deafness and a dis- 
charge. Eyes should be recorded separately, and ob- 
jective tests for eye-strain should be listed, apart from 
general symptoms. If glasses are worn, the fact 
should be noted, together with the date of their pur- 
chase and with record of the visual acuity with them 
on. Squint should be designated explicitly. Explicit- 
ness should be the rule. At the same time the record 
should not be encumbered and rendered misleading by 
the over-conscientious insertion of data pertaining to 
slight and unimportant ailments. (See page 31.) 

(6) Having an ideal individual record card, what 
shall we do with it? Some medical directors bury their 
work alive by riling it away in a distant central office. 
If a teacher wants to know the facts about the health 
of one of her pupils, she will have to make a trip to this 
office. Needless to say, under this kind of system, 
teachers and supervisors cannot be expected to know 



SCOPE AND ADMINISTRATION 33 

much about the health conditions of their children. 
The card should always accompany the pupil through- 
out his course by being transferred to each of his suc- 
cessive teachers. If the central office can afford to have 
a copy, well and good. If there is only one card, there 
ought to be no question as to where it belongs. 

Schools and publicity 

The school does not always court full publicity. 
School reports give little information as to the real 
efficiency of a school. They are too likely to give all 
the lights and none of the shadows. They are some- 
times shameless advertisements of the superintendent 
or the school board. The private individual who shows 
an interest in facts not officially revealed may be 
accused of enmity and suspected of acting from per- 
sonal motives. The following are some of the matters 
concerning which American school authorities do not 
give sufficient information : — 

(1) The amount of retardation and elimination in 
all the grades. 

(2) The intra-school and extra-school causes of such 
retardation and elimination as exist. 

(3) The efficiency of the school, as measured by its 
actual grade performances. Here, instead of any at- 
tempt at stating objective facts, the board of education 
may lay claim to having the "most efficient school 
system in the State." In the West this is changed to 
the "best in the United States." 

(4) The hygienic imperfections of its school build- 



34 HEALTH WORK IN THE SCHOOLS 

ings are seldom plainly and explicitly stated. When 
the evil is too crying to permit absolute silence, such 
statements as are allowed to appear lose all flavor of 
truthfulness either through vagueness or fragmentari- 
ness. The schoolroom which has one third the stand- 
ard amount of light, and which investigation would 
probably show to have an excessive amount of eye 
defect among its pupils, will at most be reported as 
"somewhat deficient in light," etc. School authorities 
do not tell us what school buildings are supplied with 
air dryer than the air of Sahara. They do not tell us 
anything about the relation of colds, influenza, etc., 
to the ventilation and warming of school buildings, 
nor do they enlighten us very materially in regard to 
the methods of sanitation which they employ. 

(5) Lastly, as we have already seen, they tell the 
public very little about the physical conditions of the 
children, and still less about the relation of one defect 
to others or to school and social environment. 

Not even schools can remain permanently exempt 
from publicity. For the very reason that public educa- 
tion is the institution of most vital concern to the 
entire population, those who control it are morally 
obligated to afford publicity of all the facts which con- 
cern it. The more intimate or unpleasant the facts the 
deeper is this obligation. Sooner or later, this ideal is 
certain to take possession of us. The campaign for pub- 
licity in matters of public concern will not stop at the 
threshold of the school, and we shall do well to prepare 



SCOPE AND ADMINISTRATION 35 

ourselves for it by studying a little the methods of 
scientific management. 

REFERENCES 

(Only references relating to the scope and administration of medi- 
cal inspection are included here.) 

*1. Allen, W. H.: Civics and Health. (Chapter xxx, "School and 
Health Reports"; chapter xxxiii, "Organization of School 
Hygiene in New York City"; chapter xxix, " Official Machin- 
ery for Enforcing Health Rights.") 

*2. Ayres, Leonard P.: Medical Inspection Legislation. 1911, pp. 
54. Bull. 99, Russell Sage Foundation, New York. 

3. Cornell, Walter S. : "Good and Bad Forms of Record Keeping." 
Proc. Am. Sch. Hyg. Assoc., 1911, pp. 65-72. 

4. Cornell, Walter S. : " The Need of Improved Records of the 
Physical Conditions of Children." Psychological Clinic, 1909, 
pp. 161-63. 

5. Cornell, Walter S.: The Health and Medical Inspection of School 
Children, 1912. (Chapter I.) 

6. Crowley, Dr. Ralph H.: The Hygiene of the School Child, 1909. 
(Chapter v, " Medical Inspection of the Child in the School. 
The Parent and the State.") 

*7. Gulick and Ayres: The Medical Inspection of Schools. 1913. 
(Chapter vi, "Making Medical Inspection Effective"; chapter 
x, "Controlling Authorities"; chap, xi, "Legal Provisions.") 

*8. Hoag, E. B.: The Health Index of Children. 1910, pp. 188. 
(Chapter xn, "An Office System for School Health Depart- 
ments"; chapter xm, " A General Plan for Health Supervision 
in Schools"; chapter xiv, "Some Details of the Physician's 
Examinations"; chapter xv, "The Cooperation of School 
Health Departments with Other Agencies.") 

*9. Hogarth, Dr. A. N.: The Medical Inspection of Schools. 1909. 
(Chapter vn, " The General Principles and Aims of Medical 
Inspection"; chapter vn, "The Organization of a Central 
Department"; chapter ix, "Local Organization"; chapter 
xm, "Administrative Routine"; chapter xvi, "Common 
Diseases affecting School Life.") 

10. Hope, Dr. E. S.: "Correlation of the School Medical Service 
and the Health Medical Service." In Kelynack's Medical In- 
spection of Schools, chapter i, pp. 1-10. 

11. Howcrth, Dr. W. J.: " Organization and Administration of the 
Medical Examination of Scholars." In Kelynack's Medical 
Inspection of Schools, chapter in, pp. 34-62. 

12. Mackenzie, Dr. W. Leslie: The Medical Inspection of School 
Children. 1909. (Chapters i to vi.) 

13. Porter, Charles: School Hygiene and the Laws of Health. Lon- 



36 HEALTH WORK IN THE SCHOOLS 

don, 1908. (Chapter xxn, " The Medical Inspection of Schools 
and School Children.") 
*14. Rapeer, Louis W.: School Health Administration. 1913, 
pp. 360. 

15. Snedden, David S.: "Problems of Health Supervision in the 
Schools of Massachusetts." Proc. Am. Sch. Hyg. Assoc, 1912, 
pp. 18-26. 

16. Storey, Dr. Thomas A.: "Medical Inspection in Schools from 
the Standpoint of the Educator." Medical Review of Reviews, 
July, 1912. 

*17. Newmayer, Dr. S. W.: Medical and Sanitary Inspection of 
Schools. 1913, pp. 318. (Part I.) 



CHAPTER III 

PLANS FOR ORGANIZATION FOR HEALTH WORK 

State versus local control 

Although the development of health work in the 
schools has been very rapid, much remains to be done 
to make it as effective as it ought to be. Its greatest 
weakness lies in the absence of standardized direction 
and procedure. With regard to it the most divergent 
beliefs and practices prevail. 

The logical place for the oversight of such work is 
the State, though almost everywhere in the United 
States city action has preceded state action. For the 
State to assume general responsibility for school health 
work would only be in line with other extensions of 
the State's interest in the welfare of its children, in- 
cluding state laws for vocational education, state uni- 
formity in textbooks and courses of study, state sup- 
port for secondary schools, etc. 

State action in matters relating to school hygiene 
is desirable for two important reasons: (1) it sets 
standards for the conduct of the work which insure 
that it will be, on the whole, much better done than 
is the case when each community is left to work out 
its own methods blindly; and (2) it is the best and only 
guaranty that backward communities will not neglect 



38 HEALTH WORK IN THE SCHOOLS 

such matters altogether. In the absence of manda- 
tory state laws, rural schools almost never enjoy the 
requisite hygienic oversight, either as regards school 
buildings or the children themselves. 

By 1912 some twenty States had passed laws pro- 
viding for the medical inspection of schools, but in 
only nine cases are the laws mandatory. Even where 
the law is mandatory, the details of method and pro- 
cedure are too often left to the initiative of the city, 
county, or school district, so that most of the benefits 
which would accrue from responsible state depart- 
ments of health supervision are not enjoyed. 

Examples of state departments 

In August, 1912, the State of Minnesota organized, 
for the first time in the United States, a "State Divi- 
sion of Health Supervision of Schools. " The work was 
undertaken by the State Board of Health, with the 
cooperation of the State Department of Public In- 
struction. 

A Director of School Hygiene was appointed whose 
duties were as follows : — 

(1) To visit towns and cities desiring aid in the 
promotion of school health work. 

(2) To maintain a clearing-house of information in 
matters pertaining to school and child hygiene, at the 
offices of the State Board of Health. 

(3) To offer lectures on general topics of school and 
child hygiene to teachers' institutes, and other or- 
ganizations desiring them. 



ORGANIZATION IN THE SCHOOLS 39 

(4) To conduct short courses on child hygiene at 
each of the State Normal Schools. 

(5) To carry on investigations in matters pertain- 
ing to school and child hygiene. 

(G) To publish and circulate information to schools, 
pupils, and parents on subjects relating to the pro- 
motion of health among school children. 

(7) To maintain an exhibit of school hygiene, at 
the offices of the State Board of Health. 

(8) To maintain a bureau of information in respect 
to available school medical officers and school nurses. 

The general program of the director at each place 
visited was as follows : — 

(1) A general meeting with all the teachers of the 
local school system, at which were explained methods 
for the physical observation of school children. At 
these meetings practical demonstrations (or school 
clinics) were given, with one or more grades of school 
children present, usually a fourth or fifth grade. (See 
chapter vi for a stenographic report of one such clinic 
held.) 

(2) Individual demonstrations in various grades 
in different schools. 

(3) Examination of special cases, including mentally 
defective children. 

(4) A second meeting with all the teachers for the 
purpose of discussing the results of the examinations. 

(5) An open meeting devoted to the interests of 
parents of school children. 



40 HEALTH WORK IN THE SCHOOLS 

(6) Sanitary inspection of school buildings and 
premises. 

(7) Organization of the study of mentally deficient 
children. 

(8) Recommendations for health promotion ad- 
dressed to the board of education, and adapted to the 
conditions discovered. 

The University of Virginia, in cooperation with the 
State Board of Health and the State Department of 
Public Instruction, has organized a plan somewhat 
similar to that of Minnesota, and it is safe to say that 
in a comparatively short time state organization and 
standardization of school and child hygiene will be 
undertaken by most of the progressive States of the 
Union. 

However maintained, provided only the work be 
vigorously and sanely prosecuted, the State Depart- 
ment of Child Hygiene is sure to be of incalculable 
benefit. It hastens the progress of health supervision 
not only by persuading school authorities to establish 
it, but also by standardizing the procedure so as to 
insure efficiency. By influencing legal and educational 
control it would in many cases save years of needless 
and discouraging experimentation. Such a depart- 
ment should organize and prosecute State-wide in- 
vestigations of child hygiene, in the broadest sense, 
including infant mortality, mental retardation, juve- 
nile criminality, the hygiene of mental activity, etc. 

In the organization of such departments it is de- 



ORGANIZATION IN THE SCHOOLS 41 

sirable that the work be broadly conceived, so as to 
bring within its scope as many aspects of child hygiene 
and child welfare as possible. Research should be vigor- 
ously prosecuted along all lines of mental and physical 
deviation, and should look especially toward methods 
of amelioration and prevention. There should be sub- 
departments for the hygiene of instruction, mental 
retardation, preventive mental hygiene, etc., each 
with specially trained assistants in charge. 

City organization of school health supervision 

Most of the larger cities of the country have taken 
up the work in some fashion or other, without refer- 
ence to state action. By 1898, Boston, Chicago, New 
York, and Philadelphia had inaugurated systems of 
medical inspection. About 90 cities had followed the 
example by 1907, 337 by 1910, and nearly 500 by 
1913. 

This wave of activity has resulted in (1) a few 
well-developed City Departments of School Hygiene; 

(2) many partially developed undertakings; and 

(3) a desire, on the part of many smaller cities, to 
undertake some kind of health supervision in an 
inexpensive way, without the employment of school 
physicians. 

In order to indicate some of the best plans for health 
work in schools, and in a measure to furnish standards 
which may be successfully put into operation, three 
distinct plans of organization for school health work 
are here set forth, devised to meet varying conditions, 



42 HEALTH WORK LN THE SCHOOLS 

such as are sure to exist in different places. The three 
plans are as follows : — 

(1) Organization with one or more medical officers, 
and a nurse or nurses. 

(2) Organization with a school nurse or nurses only. 

(3) Organization by the employment of a simple 
non-technical health survey on the part of the teachers 
only. Such a survey is provided by a series of ques- 
tions based upon ordinary observations of physical 
and mental conditions. 

In the present chapter, Plan (1) is set forth in a 
general way, and in the appendix the organization in 
five typical cities is described. Plan (2), supervision 
by nurses only, is described in chapter iv; and Plan 
(3), health grading by teachers^ in chapters v and vi. 

Plan (1): Physicians and Nurses 

A physician should be selected who has some special 
interest in and adaptability for work with school chil- 
dren. In addition to this he should have made some 
special study of school hygiene, since medical colleges 
unfortunately do not usually include such courses in 
their curricula. 

Whether the medical officer shall give part or all 
of his time to this work will depend largely upon the 
duties required of him. In communities where the 
number of school pupils does not exceed 4000 to 6000, 
it is possible for one well-trained school doctor to 
render satisfactory service by devoting one half of his 
time to the work, provided he has as assistants at 



ORGANIZATION IN THE SCHOOLS 43 

least two well-trained nurses who possess special 
adaptability for this kind of work. 

In places of from 8,000 to 12,000 school population, 
it is best to have one physician give his entire time, 
and an assistant physician give half-time. In such 
places there should be employed at least three or four 
school nurses. 

In places where the school pupils exceed 12,000, 
one may estimate an additional half-time school medi- 
cal officer and from one to two full-time school nurses 
for each 6,000 increase in the number of pupils. For 
a city the size of Los Angeles or Indianapolis, this 
would mean from twelve to twenty school nurses. 

Many will say that this is an inadequate force for 
so large a number of pupils, and gauged by absolute 
perfection this may be true. But it must be remem- 
bered that school systems have many practical adjust- 
ments to make, and that this is actually a larger force 
than schools now employ. 

The plan presupposes preliminary examinations on 
the part of nurses and teachers, after the manner sug- 
gested in chapter v. This method relieves the medical 
officers from much purely routine examination of 
practically normal children, and allows them to con- 
centrate their attention on children really needing 
expert services. With the methods employed at pres- 
ent, school doctors waste a great amount of time doing 
purely inexpert work, which might far better be done 
by teachers and nurses. At present most cities are in 
this way paying experts for inexpert service. 



44 HEALTH WORK IN THE SCHOOLS 

When a city is large enough to require the services 
of several medical officers in the schools, the follow- 
ing plan is suggested and recommended as the most 
efficient one : — 

There should be one general director, giving his 
entire time to the work. Instead of employing several 
half-time physicians as his assistants, fewer men on 
whole time are recommended. The organization might 
be made up as here indicated for a city of, say, 60,000 
school children: — 

One Chief Health Director. 

One General Medical Officer. 

One eye, ear, nose, and throat specialist. 

One specialist in mental and nervous diseases, who 
is also experienced in psychological methods. 

One emergency physician. 

One woman physician in charge of high-school girls. 

One dental specialist. 

This number (seven) would take the place of the 
twelve physicians under the usual plan in vogue, and, 
with appropriate increase in the number of school 
nurses, would result in better work in every respect. 

Such a plan would require a central office of several 
rooms; namely, one general reception-room; one pri- 
vate office for the director; one examining-room; one 
laboratory equipped with medical and psychological 
apparatus. There should be a dental and medical 
clinic, either in connection with the schools (and this 
is preferable), or, if this seems impossible to arrange, 
then in connection with some other organization. 



ORGANIZATION IN THE SCHOOLS 45 

With this plan in operation, parents of defective 
children would have the opportunity of taking their 
children to the central office for special examinations. 
The different specialists would keep office hours on 
different days of the week, and could thus give careful 
and deliberate attention to such school children as re- 
quired it. From this office, cards of admission to the 
medical or dental clinics could be issued to those en- 
titled to them. One special school nurse should be 
assigned for duty at the central office, whose duty it 
would be to keep the records and assist the physician 
in the examination. 1 

The cost of health supervision by Plan (l) 

The expense of a system providing for competent 
health supervision of about 50,000 school children 
would probably fall somewhere between $18,000 and 
$25,000 annually for equipment and for salaries of 
physicians and nurses. If the scope of the work is 
enlarged by the addition of one or more psychologists, 
and by extensive use of clinics for free treatment, the 
cost would be proportionately greater. 

The importance of adequate salaries deserves special 
emphasis. We frequently hear of a medical officer 
giving half-time, examining thousands of children 

1 For the benefit of those specially interested in school health 
organization, the plans of health supervision in five representative 
cities of the United States are presented, in some detail, in Appen- 
dix I. Special attention is called to the organization in Milwaukee. 
See also Rapier's School Health Administration for work in twenty- 
five representative cities. 



46 HEALTH WORK IN THE SCHOOLS 

in a school year, and receiving for his services a pit- 
tance of $200. It should go without saying that what- 
ever public service is worth having is worth paying 
for. Until salaries of health supervisors are placed on 
a better footing it is useless to expect the kind of serv- 
ice that is most needed. 

Costs are large or small relatively to other costs. 
The annual money loss to the people of the United 
States due to their ignorance and carelessness of the 
laws of hygiene has been conservatively estimated 
at not less than $2,000,000,000. It is probably a good 
deal more than that. The annual cost from tuberculo- 
sis alone is not less than $500,000,000. Our calcula- 
tion takes no account of impaired efficiency due to 
alcoholism or other vicious habits, undue fatigue, 
minor ailments, and general lack of expert direction 
of the human machine, nor does it try to place a money 
value upon grief and moral suffering resulting from 
preventable sickness or death. 

If the kind of health supervision here suggested 
were established in every city and county of every 
State in the Union, the annual cost would not exceed 
$5,000,000 to $10,000,000, or less than half of one per 
cent of our annual loss from sickness, physical in- 
efficiency, and premature death. In passing we may 
also note that this sum is about equal to the cost 
of one warship; to one sixtieth of the money cost of 
the alcoholic beverages consumed annually in the 
United States; or to one fortieth of our annual ex- 
penditure for tobacco. 



ORGANIZATION IN THE SCHOOLS 47 

It is, of course, not claimed that child hygiene in 
the schools can prevent all of the losses due to pre- 
ventable sickness, but there can be no doubt that it 
would save many times more than half of one per 
cent of them. Through education its effects would 
become cumulative. It is not unreasonable to suppose 
that in the long run the annual returns would amount 
to fifty times the annual cost. Compared to other ed- 
ucational expenditures the cost cannot be consid- 
ered large. The elementary and secondary schools 
of the United States are supported by an annual ex- 
pense of nearly $450,000,000. If ideal health super- 
vision were made universal, this amount would have 
to be increased only to the extent of about one or 
two per cent. Stating it in another way, the public at 
present is willing to expend, and does expend on an 
average, about $35 annually in the mental and moral 
education of one of its children. If it also undertook 
the hygienic supervision of the child's growth and 
development the amount would be about $35.50. 
Health supervision for the child's whole elementary 
school life would be about $3 to $4. A progressive 
city of 300,000 people and 45,000 school enrollment 
expends over $125,000 for salaries of superintendents, 
assistant superintendents, and supervising principals, 
who themselves do no teaching. It could at least afford 
to expend one fifth of this amount for health super- 
vision and hygiene investigations. 



CHAPTER IV 

THE SCHOOL NURSE: INCLUDING SUGGESTIONS FOR 

HEALTH SUPERVISION BY THE "NURSE 

ALONE" PLAN 

Spread of school nursing 

One of the latest and best additions to our educa- 
tional forces is the school nurse. Perhaps no other 
educational movement, not even excepting medical 
inspection itself, has spread with more rapidity or 
has met with such unanimity of support. 

School nursing had its beginning in England. In 
1894 a district nurse was asked to visit a London 
school attended by poor children, to help to relieve 
their ills. In 1898, a voluntary "School Nurses' So- 
ciety" was founded with the idea of extending the 
work, as a result of which three nurses were appointed. 
In 1904, when the work of the London School Board 
was taken over by the London County Council, and 
reorganized, the number of nurses was increased to 
12, and still later to 50. Other cities of England, 
large and small, speedily followed the example of 
London, and school nursing is now being carried into 
the rural districts. 

In the United States it was not until 1903 that the 
movement can really be said to have begun. In that 
year New York appropriated $30,000 for the purpose, 



THE SCHOOL NURSE 49 

and appointed 27 nurses to assist the Board of Health 
in the medical inspection of schools. By 1907, eight 
cities in the country had school nurses, and by 1910 
nearly eighty. Of these 71 per cent are located in the 
Northern States. Boston, with its force of 25 school 
nurses, supported at an annual expense of $25,000, 
is an excellent illustration of what progressive Ameri- 
can cities are doing in this line. New York City, at 
the time this is written, has 176. In all parts of the 
country the number is increasing with great rapidity. 
Special provision for the employment of school nurses 
is now made in the medical inspection laws of several 
States. 

Nurses necessary for follow-up work 

Medical inspection rendered the school nurse in- 
evitable. When the doctor was brought into the 
schools, he faced a new and tremendously difficult 
situation. The school doctor's helplessness has been 
vividly described by Dr. Hayward, of England, as 
follows : — 

As a doctor I felt quite stranded in the strange atmosphere 
of an elementary school, coming into contact, not so much 
with actual illness, as with the primary conditions which 
produce and foster it. Dirt, neglect, improper feeding, mal- 
nutrition, insufficient clothing, suppurating ears, defective 
sight, verminous conditions, the impossibility of getting 
adequate information from the children or a knowledge of 
their home conditions; and nobody to whom one could give 
directions or who could help in examining the children. The 
only means of approaching the parents was to send an official 
notice that such or such a condition required treatment. My 
duties began and ceased with endless notifications, and there 
it all stopped, as very little notice was taken of them. 



50 



HEALTH WORK IN THE SCHOOLS 



This has been the experience everywhere. Without 
an effective follow-up service, conducted by visiting 
nurses, medical inspection is ineffective. Until 1908, 
New York City relied upon a postal card notification 
sent to parents of defective children, and was able to 
secure action in only 6 per cent of the cases where 
treatment was recommended. Immediately upon 
placing the follow-up service in the hands of school 
nurses the percentage increased to 84. This brought 
treatment to nearly 200,000 additional pupils. The 
following chart shows the difference in the results 




of recommendations acted on in Philadelphia. 



THE SCHOOL NURSE 51 

obtained by a given medical inspector in Philadelphia 
after the addition of a school nurse to his staff. In 
each case the height of the first column shows the 
percentage of recommendations acted upon by the 
parents before the employment of the nurse; the 
second column after her employment. 

In a majority of cases parental neglect spells igno- 
rance. The postal card notification is a poor educa- 
tional device. The nurse goes into the home and by 
tactful presentation of the child's case effects what 
no other agency could accomplish. She not only 
secures action in the case at hand, but she becomes a 
permanent advisory influence in the homes where 
she visits. She does what the iron hand of law could 
not do. We can hardly imagine any kind of legal 
machinery, devised for compelling parental treatment 
of children's defects, which would succeed in as large 
a percentage of cases as does the school nurse. 

School nurses reduce absence 

In the second place, medical inspection without 
school nurses is always a costly tax on attendance. 
Children with scabies, impetigo, pediculosis, etc., are 
sent home by the thousand, to mingle on the street 
with other children after school hours, beyond the 
control of the school and without effective treatment. 
Where diseases of this kind are either treated by the 
nurses at school or by the parents after her instruc- 
tion, exclusions are usually reduced to 5 or 10 per 
cent of the number previously necessary. In New 



52 HEALTH WORK IN THE SCHOOLS 

York City the reduction was from about 10,000 to 
about 1000 per month. In a quarter of a school 
year exclusions were enforced in New York as fol- 
lows : — 

Measles 18 

Diphtheria 140 

Scarlet fever 13 

Whooping-cough 61 

Mumps 13 

Chickenpox 172 

Trachoma 12641 

Pediculosis 3994 

Skin diseases 661 

Miscellaneous 1823 



Nearly all 
these exclusions 
preventable by 
school nursing. 



Over 95 per cent of the above exclusions would have 
been prevented by the school nurse. By her ministra- 
tions and instruction in the home these diseases of 
filth and neglect are almost eliminated. As expressed 
by Jane Addams : * — 

The best of medical inspection succeeds only in sending 
the child home; they say that such and such a child would 
have a bad effect on the other children, and therefore he is 
sent back to the family physician for treatment. In most 
cases a family physician is not called in, because, in the words 
of ArtemusWard, "there ain't none"; and therefore the child 
is kept out indefinitely, and the public school, so far as that 
child is concerned, is doing nothing, and the child continues 
to play in the alley and on the street or sit in the doors of the 
tenement with the rest of the children. This is the whole 
idea — that medical inspection was succeeded and almost 
transposed by the addition of the visiting nurses. The med- 
ical inspection got the child out of school, and the visiting 
nurse got the child back. It seems almost foolish to have 
medical inspection without the visiting nurse. 

1 Am. J. Nursing, 1908. 



THE SCHOOL NURSE 53 

Other functions of the school nurse 

By virtue of her room to room visitation and her 
opportunities for observation, the school nurse also 
becomes the ideal sanitary inspector. She notes tem- 
peratures, ventilation, seating, cleanliness of room, 
toilets, blackboards, and the clothes of children. Her 
hospital standards of sanitation tend to follow her 
into the schools. 

In special schools for the tuberculous, crippled, or 
anaemic children, the school nurse is indispensable. 
She records body temperatures, supervises the diet, 
the sleep, and the play of the children, and advises 
continually with parents, teachers, and doctors. In 
some such schools her constant presence is as neces- 
sary as in the hospital ward. 

Again, the school nurse becomes an invaluable as- 
sistant in the teaching of hygiene to pupils. Every 
pupil ought to have more expert instruction on such 
subjects as home-nursing and first aid in emergencies 
than the average teacher can be reasonably expected 
to give. This deserves a special place in the seventh 
and eight grades. In the matter of sex hygiene, too, 
the school nurse can give much personal advice and 
instruction to the older girls. As has been pointed out 
by Miss Stewart, 1 the nurse, more than almost any 
other social worker, sees the dreadful havoc wrought 
by ignorance of the laws of sex. She becomes vividly 

1 Ninth Year-Book of the National Society for the Scientific Study 
of Education, p. 5. 



54 HEALTH WORK IN THE SCHOOLS 

impressed with the necessity of such teaching as will 
supply to young girls the power and motive for self- 
protection. Girls are willing to consult her the more 
readily because they realize that this is an everyday 
subject with her. 

Influence of school nurses upon the home 

The school nurse, like the municipal district nurse, 
is first and last a social worker. Important as are her 
duties in the school, her ministrations and educative 
influence in the home are more valuable still. She 
instructs ignorant but fond mothers in the best 
methods of feeding, clothing, and caring for their 
children. She is received in their homes as no other 
official visitor could possibly be. Mothers are quick 
to detect the genuineness of her interest in their chil- 
dren, and are often ready to follow with blind faith 
any instructions she has to offer. At her advent in a 
tenement or street, the mothers not infrequently 
crowd eagerly around her, plying her with questions 
and bringing their babies for inspection. The school 
nurse is thus a potent factor in diminishing infant 
mortality. In short, Dr. Osier does not overstate the 
case when he says that the visiting nurse is " a minis- 
tering angel everywhere. " In many a family she be- 
comes a spiritual adviser, not only pointing out in- 
adequate sanitation which keeps them sick, but also 
educating them on the folly of cut-throat chattel 
mortgages, unnecessary furniture purchased at ruin- 
ous prices on the installment plan, the short-sighted 



THE SCHOOL NURSE 55 

policy of taking children prematurely out of school 
to work, etc. 

All of this is especially important in the Ameri- 
canization of the more ignorant foreign-born popu- 
lation. As stated by Dr. Darlington, of New York 
City: — 

In all large communities, the poorer element of the foreign- 
born population presents the greatest problem encountered 
in municipal health work. Diversified in their habits, often 
superstitious and resentful of any interference with their 
mode of life, oppressed by poverty, frequently ignorant or 
neglectful of the simplest sanitary requirements, their assim- 
ilation as citizens of their adopted country comes only as 
result of education — persistent, inclusive, and never-end- 
ing. In public health work this education is brought about 
by various means. Lectures, printed instructions, and pub- 
licity in all its forms are used, but the most valuable and 
effective form is found in individual instruction in the home. 
Personal efforts, advice, instruction, and demonstration offer 
the most practical and effective means, and we have found 
the employment of trained nurses for this purpose of ines- 
timable value. 

That the visiting nurse is a good economic invest- 
ment is evidenced by the fact that some of the large 
insurance companies, such as the Metropolitan Life 
of New York City, find it to their advantage to em- 
ploy a number of them to visit the homes of policy- 
holders for the purpose of giving instruction in mat- 
ters of hygiene. Department stores and factories also 
find it good business to employ nurses to look after 
the health of their employees and to teach them 
personal hygiene. The visiting nurse is a "health 
nurse. " 



56 HEALTH WORK IN THE SCHOOLS 

Number needed 

The number of school nurses needed varies some- 
what according to social conditions, and according 
to the range of duties expected of them. We find all 
the way from 1,000 to 10,000 children under the care 
of one nurse. In New York City each nurse has from 
two to seven schools, with a total attendance of about 
4000 children. In Philadelphia five schools and about 
5000 children are usually allotted to one nurse, while 
in Boston the proportion of nurses is almost twice as 
great. Nor is it at all demonstrated that the point of 
diminishing returns has yet been reached in the num- 
ber employed. It is not improbable that the ratio 
will be increased until it reaches an average of one 
nurse for each 1000 of the school enrollment. If there 
were one nurse for every 2000 pupils, about 10,000 
would be required in the entire United States. A 
nurse's room, completely equipped, is coming to be 
regarded as one of the essentials in every school build- 
ing of eight or more rooms. 

Thus far the institution of school nursing has not 
spread to rural communities in the United States, 
though it has done so to a certain extent in England. 
This cannot be attributed to any lack of need, but 
only to the greater expense and other obstacles inci- 
dent to a more scattered population. As our country 
districts become more densely populated, and as they 
resort more often to school consolidation, the nurse will 
here, also, become a necessary part of the school force. 



THE SCHOOL NURSE 57 

Equipment needed by school nurses 

With such an extensive scope of duties, oppor- 
tunities, and difficulties, it at once becomes evident 
that both the personal qualities and the professional 
training of the school nurse are matters of great im- 
portance. She must be quick to understand every 
class and condition of people, patient, sympathetic, 
and tactful. All agree that tact is absolutely essential. 
She must be simple, direct, concrete, forceful, con- 
vincing. Her business is not to entertain, but to get 
things done, and she must therefore be persuasive 
as well as pleasing. 

On the professional side, besides having a good 
high-school education and a complete course in a 
nurses' training school of recognized standing, she 
should have had some months of additional experi- 
ence in a children's hospital. She must also know 
something of education, child psychology, general 
hygiene, nutrition, infant mortality, child-welfare 
movements, domestic sanitation, and certain legal 
matters. If she has had previous experience as a dis- 
trict nurse or as a teacher, so much the better. Good 
health and willingness to work are of course taken for 
granted. 

With the rapid multiplication of school nurses the 
desirability of special professional training for them 
will become more obvious. Teachers College, Colum- 
bia, has already introduced a one-year course for this 
purpose, designed to follow the usual two-year train- 



58 HEALTH WORK IN THE SCHOOLS 

ing for nurses. Courses of this nature will no doubt 
be established at an early date in other teachers' 
colleges, and perhaps also in connection with medical 
schools. The school nurse has proved her worth to 
the most skeptical, but her usefulness can be greatly 
enhanced by the requirement of a professional train- 
ing which gives special attention to problems of school 
hygiene. 

A Plan For the Health Supervision of Schools 
by Nurses Alone x 

This plan is adapted to places which are unable, 
or think they are unable, to procure expert medical 
service in schools. It has been amply demonstrated 
that well-trained nurses are able to accomplish ex- 
tremely useful results, even without the direct aid 
of medical supervision. The plan has been in success- 
ful operation in Alameda, California, since 1911, and 
is soon to be established at Ely, Austin, Cloquet, 
Owatonna, and a number of other towns of Min- 
nesota. 

Properly trained nurses are able to detect most of 
the physical handicaps of school children. Such nurses 
have no difficulty in discovering common defects of 
the nervous sytem, eyes, ears, throat, teeth, skin, 
and lymph glands of the neck. They can usually 
detect the presence of adenoids and note disorders of 
nutrition, as well as observe defective postures. About 

1 This is the second plan for school health supervision, mentioned 
on page 42, chapter in. 



THE SCHOOL NURSE 59 

the only points of importance which they ought not 
to attempt to cover in their examinations are those 
which pertain to certain special conditions requiring 
exact diagnosis. These would include the heart, lungs, 
special diseases of the skin and nervous system, and 
some of the unusual contagious diseases of childhood. 
Certainly more than 90 per cent of the usual defects 
of school children will be observed by the rightly 
trained school nurse, and this plan will inevitably 
justify itself and gradually lead to more thorough 
organization with medical service. 

According to Dr. R. C. Cabot, of the Harvard 
Medical School, the school nurse comes to excel the 
young doctor in detecting the first symptoms of in- 
fectious disease. The results of nurse inspection in 
Boston prove her efficiency in this line. Under the 
inspection of doctors and teachers the average number 
of cases of scarlet fever discovered annually in the 
schools was 14. In 1908, the school nurses found 1000 
cases. Where the doctors and teachers had found an 
annual average of 86 cases of measles, the school 
nurses discovered 2285! This disparity in efficiency, 
however, is in reality a disparity between nurses and 
teachers, as previous to the introduction of nurses 
the physicians had examined, for the most part, only 
those children sent to them by the teachers as suspects. 

The following communication is from Louis W. 
Rapeer, who has made an exceptionally thorough 
study of the results of medical inspection in about 
forty American cities : — 



60 HEALTH WORK IN THE SCHOOLS 

I have come to the tentative conclusion that many 
schools do not need physicians, and that a great deal would 
be gained, and little or nothing lost, by employing experi- 
enced school nurses for each group of 1000 to 1800 pupils. 
New York City, as well as other cities, has proved that 
school nurses can inspect for contagious diseases. Canton, 
Massachusetts, also has shown that only the nurse is 
needed. 1 

Physicians for less than one hour a day cost about half 
what nurses cost for full time, five and a half days a week. A 
school nurse when trained, one who has the study habit, can 
also make the physical examinations and record the findings 
on a history card for each pupil, especially for defects of ears, 
eyes, nose, mouth, throat, skin, scalp, malnutrition, and ner- 
vousness, — about 97 per cent of all. Nurses very much les- 
sen professional jealousy among the doctors; get far better 
response from children and from parents ; get cures, the great 
object of medical supervision; open the eyes of teachers 
to the symptoms of ailments and defects; follow up better the 
children they themselves examine; cooperate better with 
women's clubs, dentists, dispensaries, and oculists; get back 
the truants and absentees; keep down impetigo, lice, and 
infant mortality in the summer; distribute literature on the 
cure and prevention in the homes; and in general are on the 
job all the time as a life-work, not as a perfunctory side 
issue. Three hours each morning for inspection and 20 exam- 
inations ; afternoons for inspection and home visiting — 
about 1000 to 1800 children. 

Occasionally physicians object to allowing school 
nurses to make health examinations or to treat cuts, 
bruises, sores, and the like. The tendency, however, 
is to the extension rather than the restriction of their 
duties. There is no reason why physicians should 
view this with apprehension since the nurse's work 

1 See Dr. Arthur Cabot's article in The Physicians and Surgeon's 
Journal for May, 1911, and the September, 1911, report of the Bu- 
reau of Municipal Research, 261 Broadway, New York. 



THE SCHOOL NURSE Gl 

finds its natural limitations without any need for arti- 
ficial restriction. 

In every instance where nurses are employed to 
make the examinations of pupils, one or more physi- 
cians ought to be available for special consultation 
in questionable and unusually important cases. 

The hearty cooperation of teachers will also be 
required in this scheme and they ought to make use 
of an outline of health grading, such as that presented 
in chapter v. 

SELECTED REFERENCES 

(Only the most important references are given here. A complete bibliography will 
be found in the Ninth Year-Book of the National Society /or the Study of Education, 
referred to below.) 

1. Allport, Dr. Frank: The School Nurse. 
*2. Cornell, W. S. : Health and Medical Inspection of School Chil- 
dren. 1912, pp. 76-89. 

3. Crowley, Ralph H.: The Hygiene of School Life. 1910, pp. 181- 
83. 

4. Forbes, Duncan :" The School Nurse. " See Kelynack's Medi- 
cal Inspection of Schools. 1910, chapter xvn, pp. 264, 274. 

*5. Gulick and Ayres: Medical Inspection of Schools. (Chapter v. 

"The School Nurse," pp. 62-71.) 
*6. Hogarth, A. H. : Medical Inspection of Schools. 1909, chapter 

xii. pp. 172-86. 
7. Leipoldt, C. L.: The School Nurse. London, 1912. 
*8. Newmayer, Dr. S. W.: "Evidences that the School Nurse 

Pays." Proc. of Fifth American Cong. School Hygiene, 1911. 

pp. 44-51. 
9. Nutting, Adelaide: "The Nurse in the Public School." Rept. 

of U.S. Bureau of Education, No. 1906, chapter viii. 
*10. "The Nurse in Education," being the Ninth Year Book of the 

National Society for the Study of Education. 1911, pp. 72. 
11. Poelchau, Dr. G.: "Bericht liber die Tatigkeit der Schul- 

schwestern in Charlottenburg in Schuljahre 1909-10." Inter. 

Mag. Schulhyg., 1911, pp. 263-79. 



CHAPTER V 

THE HEALTH GRADING OF SCHOOL CHILDREN 
BY TEACHERS 1 

The General Importance of the Teacher's 
Cooperation 

The cooperation of the teacher 

The effectiveness of any system of health super- 
vision in the schools depends in large measure upon 
securing the intelligent and willing cooperation of the 
teachers. The more prominent the preventive aspect 
of the work done, the more important this becomes. 
A large part of the doctor's advice has to be acted 
upon finally, if at all, by the teacher. She is the only 
person in constant attendance upon the pupils. She 
has even larger opportunity than the school nurse to 
detect the first symptom of contagious disease in the 
school. It would be well if normal schools afforded 
to young teachers a more satisfactory training in 
school hygiene. They would then be able to cooperate 
more intelligently in the management of all kinds of 
atypical children, — the precocious, the mentally de- 
fective, the incorrigible, the physically defective, the 
timid, the quarrelsome, the stuttering, the neuras- 
thenic, etc. 

1 This is the third plan for the health supervision of schools men- 
tioned on page 42, chapter in. 



HEALTH GRADING 63 

The teacher's part in molding the health habits of 
pupils is equaled by that of no other agency. It de- 
volves upon the teacher to cultivate habits of posture 
which will prevent spinal curvature and myopia, and 
habits of physical activity which will help to counter- 
balance the effects of sedentary life and ward off 
disease. It is her duty to impart the knowledge of 
hygiene and ideals of correct living which will func- 
tion throughout life as the cheapest form of health 
insurance and the most effective protection against 
immorality and vice. The responsibility of the school 
for the child's health does not cease with the close of 
school life. 

Besides assisting the physician, with records and 
other routine work, teachers are also frequently 
charged with the testing of vision and hearing. This 
practice has become especially common in the United 
States. At present legal enactments in many States, 
including Colorado, Connecticut, Indiana, Maine, 
Massachusetts, Minnesota, and Utah, provide that 
sight and hearing tests be made by the teacher, and 
such tests are the custom in probably a majority of 
American cities. To a less extent this has been done 
also in England and Scotland. 

Teachers vs. physicians 

Physicians sometimes oppose this extension of the 
teacher's work into a field which they regard as one 
that should be reserved for a higher degree of ex- 
pertness than the average teacher can be expected to 



64 HEALTH WORK IN THE SCHOOLS 

possess. Some of the best oculists and aurists in the 
country, however, have taken the other view. In- 
deed, it has been largely due to the influence of such 
specialists themselves that these routine examina- 
tions have been so generally entrusted to teachers and 
nurses. In 1906, when the legislature of Massachu- 
setts was considering a mandatory provision by which 
vision and hearing were to be tested by teachers, 
sittings were held during which a mass of evidence as 
to the feasibility of the plan was offered by some of 
the best-known specialists of the State. Tests of the 
kind here referred to can be made by any one who is 
competent to teach. It is not claimed that the teacher 
can assume the expert functions of the oculist or 
aurist, and the making of sight and hearing tests does 
not require that they should do so. It is claimed, and 
is now fairly well recognized, that they are at least 
as capable of making tests of the special senses as is 
the physician who is not also a specialist. It should 
be stated, however, that, wherever this policy is fol- 
lowed, the intention is to have examinations made by 
specialists in all cases where defects are apparently 
revealed by the teacher's test. 

Teachers should have special instruction and prac- 
tice to aid them in reading the health index of the 
child for all the common diseases and defects. 

The contribution that can rightfully be expected 
from teachers in all these lines depends in part upon 
the size and efficiency of the school nursing corps. 
In general, the more nurses the less it will be neces- 



HEALTH GRADING (i5 

sary to require of the teachers. This applies especi- 
ally to the detection of contagious diseases and physi- 
cal defectiveness, first-aid work, follow-up service, 
etc. But the responsibility of conducting the activi- 
ties of the school in such a way as to transgress as 
little as possible the fundamental laws of hygiene is 
one which the teacher can never wholly shift. Any 
scheme of medical inspection or health supervision 
which does not succeed in enlisting the interests and 
enthusiastic support of the teachers fails in one of the 
most fundamental requirements. 

An Outline for the Health Grading of School 
Children by Teachers 

Health supervision of schools, must in many places, 
at present, be delegated largely or entirely to teachers, 
a fact which we cannot ignore. For this special work, 
however, very few teachers, or even nurses, have 
received adequate training. 

In order to help meet this condition as it exists in 
the schools, the following Outline for a Health Survey 
of School Children is suggested. Its use will succeed 
not only in largely removing the usual obstacles to 
health supervision in a community, but even where 
such obstacles do not exist, the plan when put 
into operation will, it is believed, greatly assist 
those engaged in the health care of children in the 
schools. 

The plan consists of two parts : — 

I. An outline for a partial health survey to be made 



66 HEALTH WORK IN THE SCHOOLS 

by the aid of the pupils themselves, or, in the case of 
young children, by the aid of parents. 

II. An outline for a more extensive health survey 
on the part of teachers (or nurses). Whether a medical 
officer and nurse are employed, or not, does not much 
affect the plan; although, of course, any scheme for 
health supervision in schools will succeed best where 
competent, specially trained professional service is 
available. 

The answers to these questions on the part of pupils 
or their parents will furnish some very definite in- 
formation in respect to physical and mental condi- 
tions, and prove valuable to every teacher. The 
answers under Part II will stimulate and encourage 
observation on the part of the teacher and will also 
supply a very considerable amount of useful informa- 
tion which may serve as a basis for practical hygiene 
teaching. With the employment of this survey, no 
school need wait for the appointment of a medical 
officer before beginning some effective health work 
with school children. 

In making the survey the teacher may take her own 
time. If it is completed in a room of twenty to forty 
pupils in a month or six weeks, it will be quite satis- 
factory. Any teacher will be able to accomplish it 
without feeling that she is imposed upon. After a 
pupil's health survey is made, a notice should be sent 
to the parents in those cases where physical difficulties 
appear to exist. This notice may be very general and 
noncommittal in character, and should always be 



HEALTH GRADING 67 

signed by the principal of the school. Such a notice 
has been successfully employed in the following 
form: — 

To the Parent of 

The teacher of this child has reason to believe that 
he is suffering from physical defects, serious enough 
to need attention. An examination by your family 
physician or dentist is, therefore, advised. 

For further details you are invited to call at the 
office of the Principal at any time you may find it 
convenient. 

Very sincerely yours, 
Principal of School. 

A health survey carried out in the manner suggested 
will result: — 

(1) In overcoming most of the prejudice against 
physical examinations of school children. 

(2) In educating the public in matters of child 
hygiene and preventive medicine. 

(3) In largely solving the question of expense. 

(4) In the discovery of probably 90 per cent of the 
urgent cases of physical defects. 

(5) In considerably decreasing the wear and tear 
on the teacher. 

(6) In considerably increasing the children's health, 
happiness, and efficiency. 

(7) In serving as a useful preliminary examination 
for a medical officer of schools so that he may know 
where to concentrate his attention. 

(8) In giving positive information in respect to 
the kind of hygiene teaching which is most needed. 

The significance of all the answers obtained by the 



68 HEALTH WORK IN THE SCHOOLS 

use of the questions in the health survey may not 
at first be appreciated by the teacher or other person 
without medical training, but experience and a little 
study will gradually make this matter plain. 

Part I of Health Survey 

Questions to be answered by pupil or parent, or by pupil with 
aid of the teacher 

Name. ./. School Date 

% 
Question 1: How old are you? 

Answer: 9> 

Question 2: What grade are you in? 

Answer: ^.ir£. 

Question 3: Have you ever had any serious sickness? What 
was it? 

Answer: ; 

Question 4 : What do you usually eat for breakfast? 

Answer: 

Question 5: Do you eat breakfast every day? 

Answer: 

Question 6: Do you eat a noon meal every day? 

Answer : 

Question 7: Do you drink coffee? How much? 

Answer : 

Question 8: Do you drink tea? How much? 

Answer : 

Question 9 : Do you have your bedroom window open or 
shut at night? 

Answer: 

Question 10: Have you ever been to a dentist? 

Answer : 

Question 11: Do you own a toothbrush? 

Answer : 

Question 12: Do you use a toothbrush? 

Answer: ; 

Question 13: Do you sometimes have toothache? 

Answer : 



HEALTH GRADING 69 

Question 14: Do you have headache often? 

Answer: jH.0 

Question 15: Can you read easily what is written on the 
blackboard? 

Answer : 

Question 16: Does the print blur in your book? 

Answer: 

Question 17: Do you often see double? 

Answer: rH^rf 

Question 18: Do youever have earache? 

Answer: IA-& - 

Question 19: Do your ears ever run? 

Answer: j^y([/0 

Question 20: Can you hear easily what the teacher says? 

Answer : 

Question 21 : Is it hard for you to breathe through your nose? 

Answer: .'...'■ 

Question 22: Do you have sore throat often? 

Answer: 

Question 23: Do you tire easily in school? 

Answer: 

Question 24: Do you work any out of school hours? 

Answer : 

Question 25: What kind of work? 

Answer: 

Question 26: How much? 

Answer: .' ! .'. / .' 

Additional optional questions 

Question 27: What time do you go to bed? 

Answer : 

Question 28: What time do you get up? 

Answer : 

Question 29 : Does any one else use your toothbrush? 

Answer : 

Question 30: Do you eat candy every day? 

Answer : 

Question 31: How often do you bathe? 

Answer: 

Question 32: Do you often take cold? 

Answer : 



70 HEALTH WOKK IN THE SCHOOLS 

Part II of Health Survey 
Questions to be answered by the teacher or nurse 



1. 

2. 
3. 
4. 
5. 
6. 
7. 
8. 
9. 

10. 



A. General appearance 

Is the child healthy appearing? 

Is his color good? 

Is he physically well developed? 

Is he free from apparent deformities? 

Has he a good standing posture? 

Has he a good sitting posture? 

Are the shoulders even? 

Does the child walk normally? 

Are the two sides of the shoe heels worn 

evenly? 

Is the physiological age of the child appar- 
ently equal to his chronological age? 

B. Mental conditions 

Is the child normally advanced in school? . . 

Is he mentally alert? 

Does he answer ordinary questions intelli- 
gently? 

Does he play normally? 

C. Nervous conditions 

Is the child good-tempered? 

Is he free from abnormal emotion? 

Does he have good powers of muscular coor- 
dination? 

Is he free from spasmodic movements? 

Is he free from the nail-biting habit? 

Does he speak without stammering? 

Is he free from pronounced peculiarities such 
as irritability, timidity, embarrassment, 
cruelty, moroseness, fits, general misbe- 
havior, etc.? 

Is he apparently free from bad sexual habits? 



Yes 



No 



HEALTH GRADING 



71 



9. Is he free from so-called "bladder trouble" 

(requests to "go out")? 

10. Is he usually free from headache? 

D. Teeth 

1. Are the teeth clean? 

2. Are the teeth sound? 

3. Are the six-year molars in good condition? 

4. Has the child been to a dentist within six 
months? 

5. Are the teeth regular? 

6. Does the child use a toothbrush every day?. 

7. Are the gums free from abscesses? 

8. Are the gums healthy-looking? 

9. Are the upper teeth straight (not prominent) ? 
10. Have decayed teeth been filled? 

E. Nose and throat 

1. Does the child breathe with the mouth closed ? 

2. Is he free from chronic nasal discharge? 

3. Is he free from "nasal voice"? 

4. Has he a well-developed face? 

5. Has he a well-developed chin? 

6. Has he straight, even teeth? 

7. Is the child mentally alert? 

8. Is he usually free from sore throat? 

9. Is the hard palate wide (not high and narrow) ? 

10. Is the hearing good? 

11. Does the child breathe quietly? 

F. Ears 

1. Does the child usually answer questions 
without first saying "what"? 

2. Is he fairly attentive? 

3. Is he fairly bright appearing? 

4. Does he have a voice which is not monoto- 
nous and not "expressionless"? 

5. Does he spell fairly well? 



Yes 



No 



72 



HEALTH WORK IN THE SCHOOLS 



6. Does he read fairly well? 

7. Is he free from earache? 

8. Does he hear a watch tick as far as the aver- 
age child? 

9. Is he free from ear discharge? 

10. Is he free from any peculiar postures which 

might indicate deafness? 

G. Eyes 

1. Are the child's eyes straight? 

2. Is he free from chronic headache? 

3. Does he do his work without fatigue? 

4. Is he free from squinting or frowning? 

5. Is the child free from postures which might 
indicate eye defects, such as leaning over too 
near the desk, holding the head on one side, 
etc.? 

6. Are the eyes free from corneal ulcers or scars? 

7. Are the eyes free from redness and discharge? 

8. Are the eyelids healthy-looking? 

9. Can the child read writing on the board from 
his seat? 

10. Have the eyes been tested separately with 
the Snellen Test Type? 

H. Communicable diseases of the skin 

1. Is the head free from any signs of disease 
(lice, ringworm) ? 

2. Is the skin of the face, hands, wrists, fore- 
arms, and chest free from red, somewhat cir- 
cular patches (ringworm) ? 

3. Is the skin of the face, hands, and forearms 
free from infected spots with crusts and pus 
(impetigo) ? 

4. Is the child free from red, scratched lines and 
spots on the hands, wrists, forearms, chest, 
and between the fingers (itch) ? 



Yes 



No 



HEALTH GRADING 



73 



/. Eruptive children's diseases 

The following points often indicate the early signs of trans- 
missible diseases in children. They will not ordinarily be 
observed, of course, at the time of making this health sur- 
vey:— 



1. Flushed face 

2. Lassitude 

3. Vomiting 

4. Eruptions 

5. Congested eyes 

6. Discharging eyes . . . 

7. Nasal discharge 

8. Persistent coughing 

9. Scratching 

10. Aches and pains. . . . 

11. Sore throat 

12. Headache 



Yes 



No 



74 HEALTH WORK IN THE SCHOOLS 

BLANK FOR SUMMARY 

Physical Development 

Nervous System 

Nutrition 

Mental Condition 

Eyes 

Ears 

Nose i. . . . 

Throat 

Teeth 

Skin 

Eruptive Disease 

Food 

Ventilation of Bedroom 

Coffee Habits 

Tea Habits 

Home Habits , 



HEALTH GRADING 



75 



ABBREVIATED CARD FORM OF A TEACHER'S 
HEALTH SURVEY OF THE SCHOOL CHDLD 



Name School 

Grade Age. 

Date 



Yes 



No 



1. Have you ever been in a grade more than 
one year? 

2. Have you ever had any serious sickness?. 

3. Do you feel strong and well now? 

4. Do you eat breakfast every day? 

5. Do you eat a noon meal every day? 

6. Do you drink coffee? 

7. Do you always have your bedroom win- 
dow open at night? 

8. Have you been to a dentist within a year? 

9. Do you have toothache often? 

10. Do you own a toothbrush? 

11. Do you use your toothbrush every day?. . 

12. Do you have a toothbrush of your own? . 

13. Do you have much trouble with headache? 

14. Can you read writing on the blackboard 
from your seat? 

15. Does the print in your books run together 
or look dim or crooked? 

16. Do your eyes hurt after reading a good 
while? 

17. Do you sometimes see two letters or two 
lines instead of one? 

18. Do you often have earache? 

19. Do your ears ever run? 

20. Can you always hear the teacher? 

21. Do you go to bed by nine o'clock? 

22. Do you go to bed by ten o'clock? 

23. Do you bathe at least once every week?. . 

24. Have you ever been vaccinated? 

25. Have you ever had smallpox? 



76 HEALTH WORK IN THE SCHOOLS 
Remarks : — 



This child has had the following diseases at the age indicated below: — 



Chickenpox when years old Whooping-cough when years old 



Diphtheria 
Measles 
Tonsillitis 
Mumps 
Scarlet fever 



Pneumonia 
Typhoid fever 
Smallpox 
Tuberculosis 
Infantile paralysis 



HEALTH GRADING 77 

Suggestions for Using the Outline for Health 
Grading 

1. Call the pupils, one at a time, to the desk. Begin 
with Part I, and ask the questions as they appear 
in the Outline and write the answers yourself. One 
can get a great deal of information by noticing the 
manner in which the pupil answers the question. 
Mistakes in answers may often be corrected in this 
way, when they would not be observed if the pupil 
were to answer the questions himself in his own writ- 
ing at his seat. Do not suggest the answer. 

2. In asking questions about headache and ear- 
ache, or any other questions where the word "fre- 
quent" appears, use the word " frequent " as meaning 
once a week or oftener. 

3. Be perfectly sure that the pupil understands the 
question, and test his answer in a number of different 
ways where you have any reason to doubt the reply 
given. 

4. It is desirable to have the Outline for Health 
Grading completed for every pupil in your room be- 
fore the arrival of the visiting physician. 

5. After the completion of the health grading in 
your room, make a list of the pupils who you think 
ought to receive further examination by a phy- 
sician or nurse. Where only the minor difficulties 
are discovered it is not necessary to call the atten- 
tion of a physician to these points, although it may 
sometimes be necessary, by means of the blank no- 



78 HEALTH WORK IN THE SCHOOLS 

tice, to inform the parents of what you discover. Do 
not place any pupils on the list to be examined by a 
physician unless you have a definite reason for doing 
so. 

6. Make a list of all the retarded pupils in your 
room, and of this number indicate those whom you 
suspect of being mentally deficient. 

The Significance op the Answers to the 
Questions op Part I op the Outline 

The answers in Part I will furnish information on 
the following points: — 

1. Retardation. 

2. Influence of previous sickness on present condition. 

3. Relation of home habits to individual health. 

4. Condition of the teeth. 

5. Condition of the eyes. 

6. Condition of the ears. 

7. Condition of the nose. 

8. Condition of the throat. 

9. Amount of work done out of school. 
10. Food habits. 

Defective teeth 

If a child in the third grade or above has never been 
to a dentist, it is presumptive evidence in most cases 
that his teeth are defective. Testimony of aching 
teeth always indicates defective teeth; sound teeth 
never ache. 

In nearly every room it will be noted that several 
pupils make use of a family toothbrush. Nothing could 
more effectually spread disease than this practice. 







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1 


1 




a 


a 


5 


3 


3 




o 
P 


.2 


8 




§ 


1 

i 


'-3 
a 

o 


1 

o 


H 


5 

$ 


? 

1 




< 


U 


O 


P 


H 


« 



80 HEALTH WORK IN THE SCHOOLS 

Practically every school disease that we know about 
is spread by the secretions of the nose and throat. 
This clearly indicates the danger from the use of the 
common toothbrush. 

Chronic- headache 

Chronic headache in school children is usually 
caused by one of the following conditions: — 

1. Eye-strain. 

2. Indigestion. 

3. Constipation. 

4. Auto-intoxication, or absorption of the products of 
fermentation from the intestines. 

5. Decayed teeth. 

6. Bad ventilation at home, or at school, or both. 

7. Malnutrition. 

8. Adenoids. 

While there are some other causes of headache, they 
are so infrequent as to be negligible here. Of the above 
causes given, eye-strain, constipation, and auto-intoxi- 
cation are probably the most common. 

Eye-strain 

Blurring of the print always indicates some form 
of visual defect and is, therefore, positive evidence of 
eye-strain. It is always well to ask if the pupil habit- 
ually sees double; also if he notices spots before the 
eyes, if the letters appear to move, etc. 

Earache 

Chronic earache always indicates more or less seri- 
ous trouble. It means that inflammation is present 



HEALTH GRADING 81 

in the ear. In many cases earache is due to the pres- 
ence of adenoids, and frequent earache always indi- 
cates either adenoids or some other abnormal con- 
dition of the throat. If not corrected, earache very 
frequently leads to more or less permanent deafness. 

Discharging ears 

This condition is more serious than earache, and 
indicates that the disease process in the ears is ad- 
vancing rapidly. The condition should always be 
treated at the earliest possible time. Always test the 
hearing of pupils who have earache or ear discharge 
by means of the watch tick or whispered words. As 
a check in this test always test children with normal 
hearing at the same time. Test each ear separately. 

Difficult nasal breathing 

Children who complain of constant difficulty in 
breathing through the nose usually have adenoids. 
Sometimes the obstruction is in the nose itself and in 
this case is due to enlarged turbinates or to polypi. 
Many children with adenoids will say they can breathe 
easily through their noses simply because they have 
never breathed normally, and do not, therefore, know 
what nasal breathing means. Inquire if the child's 
mouth is usually dry when he wakes in the morning. 

Frequent sore throat 

This condition nearly always indicates diseased 
tonsils, and should always receive prompt attention. 



82 HEALTH WORK IN THE SCHOOLS 

If the tonsils are much enlarged, adenoids will nearly 
always be found present. On the other hand, adenoids 
are often found present when there is no enlargement 
of the tonsils. Rheumatism is often associated with 
diseased tonsils. So-called "growing-pains," stiff- 
neck, and tender, aching joints are common symptoms 
of rheumatism. 

The Significance of Answers to Part II 

General appearance 

There are many reasons for poor general appearance. 
The most common is probably general malnutrition, 
due commonly to insufficient food, the wrong variety 
of food, or the wrong use of food. Some other causes 
are the following: — 

Adenoids. 

Diseased tonsils. 

Bad ventilation. 

Very rapid growth. 

Tuberculosis. 

A recent sickness of some kind. 

Very defective teeth. 

Peculiarities in posture, walk, etc. 
These conditions may be explained in general by 
weak muscles, due to rapid growth; spinal disease 
(often tubercular); flat-foot or weakened arches; rick- 
ets; tuberculosis of knee-joint or hip-joint; paralysis, 
from some serious disease, such as infantile paralysis, 
meningitis, or diphtheria. 



HEALTH GRADING 83 

Mental conditions 

A child who is two years or more retarded in school, 
who does not play normally, or who is not mentally 
alert, should always be suspected of being mentally 
deficient. He should be tested by the Binet method. 1 
It is necessary to distinguish between merely dull and 
mentally deficient children. Many mentally deficient 
children show none of the physical signs of such a con- 
dition, and may be the best-looking children in the 
class. Be careful not to overestimate the intelligence 
of the old, mature child who is two or three years re- 
tarded, even though he does fairly good work in a 
class of much younger, less mature children. He must 
be judged by the ability of children of his own age, 
and not by children younger than himself. 

Nervous conditions 

Stammering is nearly always a nervous condition, 
and is not usually due to physical defects. Nail-biting 
is almost never a mere habit, but is caused by an un- 
stable condition of the nervous system. Spasmodic 
movements should always be carefully observed, as 
they often indicate St. Vitus' dance or habit-spasms. 
True hysteria is very seldom observed in school chil- 
dren. General nervousness is indicated by a lack of 
repose, too much emotion, inability to keep quiet, 
etc., and may be due to any of a large number of 
causes. Sometimes the home conditions will offer the 
1 See p. 105. 



84 HEALTH WORK IN THE SCHOOLS 

explanation. Often the child is from a nervous family. 
Sometimes the trouble is due to bad sexual habits, but 
more often the sexual habits are due to an unstable 
nervous system. So-called "bladder trouble" is 
practically always a sign of general nervousness, and 
usually has nothing at all to do with the condition of 
the kidneys. 

Nose and throat 
Adenoids are usually indicated by a nasal voice, 
frequent colds, crooked and prominent teeth, mouth- 
breathing, and mental dullness. Not all of these con- 
ditions are always present, but some of them are. 
Adenoids and enlarged tonsils are usually associated. 

Ears 
Never forget the relation between adenoids and 
earache, discharging ears, and deafness. 

Eyes 
Children with crossed eyes nearly always have a 
defect of vision, and the crossed eye will in time usu- 
ally become blind, or nearly so. These children should 
have properly fitted glasses at the earliest possible 
moment. This will often straighten the eyes and save 
the sight. Defective eyes are often indicated by red 
lids or red eyes, blurred vision, double vision, etc. The 
teacher should test the sight of each child by using 
the Snellen Test Type. 1 

1 The Snellen cards, together with directions for their use, can be 
secured from any book-dealer for a few cents. A set should be kept 
in every schoolroom. See chapter vi, p. 95. 



HEALTH GRADING 85 

Skin 

Any sudden eruption should always be noted as 
possibly indicating a contagious disease, such as 
measles, chickenpox, scarlet fever, and the like. No 
sort of skin disease should ever be ignored; its cause 
must be discovered. 

Examine the teeth of the children yourself 

Stand in a good light, have the children file past 
you and open their mouths as widely as possible. Take 
a quick look at all of the teeth and make a note of 
each child who has defective teeth. It is not neces- 
sary to note the number of such teeth, for every de- 
fective tooth ought to receive immediate attention. 

Some general observations 

Try to discover what children always have coated 
tongues. This is most always due to constipation. 
Try to correct this condition among children, as it is 
extremely common and usually receives very little 
attention at home. 

Attempt to learn the home habits of the children 
under your care. You will be surprised to learn how 
many keep very late hours. Try to learn the cause for 
this. Try to learn how many children eat candy every 
day. Talk to them about bathing habits, and learn 
what their habits actually are in this respect. Make 
a list of the children who live in families where there 



86 HEALTH WORK IN THE SCHOOLS 

is chronic sickness, and discover what the sickness is. 
Always be on the alert for signs of children's conta- 
gious diseases when they first manifest themselves. 
Use the information obtained by the Outline for 
practical teaching in matters of hygiene, in your parti- 
cular room. This will furnish a more effective basis 
for useful health teaching than anything else. 

Part III: Some Results secured by the Outline 
for the Health Grading of School Children 

In order to test the usefulness of the method for 
health grading of school children, and also to demon- 
strate to teachers actual conditions in their rooms, 
thirty-three grades were questioned on Part I of the 
Outline. 

In obtaining the answers, the physician asked the 
questions, one at a time, of the entire roomful of 
children, their answers being indicated by rising. 1 
At this time no individual names were recorded. The 
tabulated results which appear below are remarkable 
not only as indicating the number of physical handi- 
caps which may easily be discovered, but also in re- 
spect to the uniformity found in different schools of 
the same and widely separated towns and cities. No 
one can possibly read these results, so easily obtained, 
and remain unconvinced of the seriousness of the de- 

1 To avoid suggestion it is better to secure the data by question- 
ing each pupil privately whenever time permits. If this is impossi- 
ble, the pupils should be urged to state the exact facts, without pay- 
ing any attention to the answers given by other children. 



HEALTH GRADING 



87 



fects from which at least 40 to 50 per cent of school 
children suffer. 

The accompanying table summarizes the answers to 
" survey " questions in ten cities and towns of Min- 

TABLE I 

Answers to "Survey" Questions Addressed to 3215 
Minnesota Children 



Name of 
Town or City 


2 


a 

< 


IH 

o 

a 
© 


2 

M 
M 
O 

'A 


9 

.9 
3 
u 

<D 

"o 
O 


60 

a 
3 

a 


J 
o 
A 

3 
o 


a 
u 
a 

a 

fa 


o 1 

o 

5 


a 
o 

"Sd 

a 

1 
y 

fa 


c 
s 
« 

u 

V 

Pk 


Total Pupils 


187 


582 


299 


247 


210 


272 


425 


278 


690 


125 




Coffee 


159 


353 


238 


159 


151 


221 


364 


175 


526 


87 


75+ 


Tea 


65 


121 


90 


80 


83 


61 


213 


X 


78 


52 


29+ 


No Ventilation 
in bed-room 


101 


222 


180 


124 


122 


174 


207 


50 


221 


54 


45 


Headache 


43 


139 


61 


81 


29 


50 


86 


80 


116 


41 


22 


Poor Vision 


33 


97 


37 


57 


27 


25 


42 


52 


53 


18 


13 


Earache 


12 


80 


35 


32 


18 


26 


31 


23 


34 


9 


10— 


Running Ear 


5 


27 


10 


11 


5 


9 


12 


4 


7 


1 


3— 


Poor Hearing 


10 


43 


21 


10 


10 


7 


16 


9 


4 


6 


4 


Nasal Obstuction 


8 


68 


29 


19 


31 


14 


32 


X 


14 


11 


6+ 


Toothache 


43 


258 


57 


75 


73 


73 


151 


55 


129 


27 


80- 


Double Vision 


8 


20 


5 


11 


X 


5 


13 


11 


3 


X 


2.5 


Common 
Tooth Brush 


25 


X 


45 


11 


X 


7 


84 


X 


33 


12 


9+ 


Bad Teeth 


X 


29S 


137 


131 


60 


195 


233 


94 


370 


59 


50 



88 HEALTH WORK IN THE SCHOOLS 

nesota, in which 3215 children are included. 1 In a few 
cases certain questions were omitted. This is indi- 
cated in the table by crosses, X. It will be noted that 
the data, on the whole, are remarkably uniform. 

Tabulation of the replies by grades showed that as 
children pass beyond the sixth grade nearly all the 
conditions improve. This includes earlier hours for 
retiring (because parents take young children out 
with them at night), far better ventilation in bed- 
rooms, and a better condition of teeth due to the 
completion of second dentition. 

Of 2500 grade children questioned, 75 per cent make 
a breakfast entirely, or almost entirely, of starchy 
foods. Only 15 per cent of the 2500 have fruit of any 
kind for breakfast. The following are the usual break- 
fasts of these children : — 

1. Coffee, bread and butter. 

2. Coffee and oatmeal. 

3. Coffee and some other cereal. 

4. Coffee and hot cakes. 

5. Coffee alone. 

6. Coffee and biscuits. 

7. Coffee and coffee-cake. 

8. Bread and butter alone. 

Is it any wonder that nearly 23 per cent have fre- 
quent headaches? 

1 At a later date 6000 additional children were questioned with 
practically the same results. 



HEALTH GRADING 89 



REFERENCES 

1. Altschul, Dr. Theodore: "Cooperation between Doctor and 
Teacher." Proceedings, Third Interna? 1. Cong. Sch. Hyg., 1910, 
vol. ii, p. 199 ff. 

2. Delearde, Dr.: "Collaboration du m&iecin et du maitre en 
hygiene scolaire. " Ibid., p. 382^". 

*3. Hay ward, Dr. John A. : " Cooperation of the Teacher, Doctor 
and Nurse in Medical Inspection." Proceedings, Second Inter- 
nat'l Cong. Sch. Hyg., 1907, pp. 469 ff. (See same volume, 
p. 435.) 

*4. Hoag, Dr. E. B.: "The Teacher's Relation to Health Super- 
vision in Schools." Bull. Am. Acad. Med., June, 1912. 

*5. Hoag, Dr. E. B.: "Organized Health Work in the Schools," 
Bull, U.S. Bur. Ed., 1913, pp. 55. 

*6. Standish, Dr. Myles: "Should Examinations of Eyes of School 
Children be conducted by Teachers or by School Physicians?" 
Proceedings, Fifth Am. Cong. Sch. Hyg., 1911, pp. 98-101. 
7. Walsh, Dr. S. B.: "The School Teacher as a Factor in Public 
Health." School Hygiene, 1912, pp. 208-13. 



CHAPTER VI 

A DEMONSTRATION CLINIC FOR INSTRUCTION IN 
THE OBSERVATION OF DEFECTS 

For the purpose of instructing teachers and school 
nurses the "Demonstration Clinic" has proved of the 
greatest possible assistance. From fifty to one hun- 
dred and fifty pupils from various grades, preferably 
the third, fourth, and fifth, are assembled in the pres- 
ence of all the teachers (and school nurses, if there 
are any). The physician in charge of the "clinic" 
then proceeds to demonstrate the health conditions 
of the pupils present. To indicate exactly how the 
demonstration clinic may be carried out, a verbatim 
report is given here of one held by Dr. Hoag, in a 
small Minnesota city, with eighty-five children from 
the third, fourth, fifth, and sixth grades present. A 
summary of sixteen other demonstration clinics, held 
in Minnesota cities and villages, is also given in a 
table at the end of the report. 

Verbatim Report of a Demonstration Clinic 

Object of the clinic 

The object of this demonstration is to show teachers how 
easy it is to detect the ordinary physical defects from which 
children suffer. Most people have the idea that it is neces- 
sary to have an expert go into the schools to find these handi- 
caps, but any teacher, after a little instruction, can discover 



A DEMONSTRATION CLINIC 91 

the ordinary handicaps almost as well as any expert can. 
Only the larger places in the country have any health super- 
vision of schools that is really worthy of the name, and the 
reason is that they think only experts can do the work. Now, 
as a matter of fact, all the schools everywhere need to have 
this sort of health work, and in many instances the only way 
they can obtain it at present is to have the teachers them- 
selves attack the problem. 

The ordinary handicaps that we find in children are about 
the same everywhere we go, whether it is in a California town 
or in a Minnesota town; and the proportion of the defects 
that we find is practically the same everywhere; so that I 
could say in advance in this place just about how many cases 
of adenoids will be found, how many cases of visual defects, 
how many of chronic earache, how many of headache, how 
many of defective teeth, etc. 

We are not looking for sick children, as that word is ordi- 
narily used, and we do not often observe sick children in the 
schools, but we do find a very considerable number who have 
physical or mental handicaps which interfere with their 
school progress, and it is these handicaps which we wish to 
discover and if possible have corrected. We do not realize, 
for instance, that a large number of children suffer from 
chronic headache who never say a word about it unless they 
are questioned. They take it as a matter of course and be- 
come accustomed to it. We do not realize that a very con- 
siderable proportion of children have more or less chronic 
earache, and yet never mention it unless the earache is so 
bad that they cannot sleep at night. We do not realize that a 
large number of children have toothache, some of them most 
of the time; that they have visual defects so severe in many 
cases that they do not read comfortably or well. They suffer 
from various handicaps of this sort and never say anything 
about it, simply because they are accustomed to the condi- 
tion and very often know no other. They have no standard 
of comparison. Children in the main never complain about 
their physical handicaps unless they are so serious as actually 
to make them sick, and this is a point which we must always 
remember in dealing with them. 



92 HEALTH WORK IN THE SCHOOLS 

Purposes and methods of work 

Now what I want to do here this afternoon is to ask these 
eighty-five children some very simple, commonplace ques- 
tions, just as I would like to have you do with your children 
in the various grades, and the answers to these questions will 
indicate pretty accurately the sort of physical handicaps 
which are present. I shall have to ask the questions of the 
whole group and not take down any individual names, but 
teachers in gathering such information ought to record each 
child's examination separately and make it a permanent 
school record. 

As a matter of fact, at least twenty -five per cent of school 
children have visual defects of some kind or another. These 
are ordinarily discovered by the use of the test-type card, but 
without any card or apparatus of any sort you can still dis- 
cover a very considerable number of eye defects by a simple 
question. In order to demonstrate this point, I am going to 
ask these children the question and they will answer by ris- 
ing, and the question is this — "Now, children, I want you 
to listen carefully, and do not answer until I am all through. 
How many of you notice when you read in your books that 
the print is hard to see, or that it often looks dim, or per- 
haps crooked, or that you see two letters instead of one, or 
two lines instead of one, or that in some way you find it 
hard to read ? " 

The number of children who are standing is eighteen, and 
we will now try to discover, by some further questions, 
whether these children really know what they are talking 
about or not. The children will give answers of a certain 
type, and these answers will be exactly such as children give 
in other places and in almost exactly the same words, for the 
simple reason that they have the same defects that children 
in other places have. I want to ask the teachers to please 
listen carefully to the responses which are made when we ask 
the children about their eyes. 

Condition of the eyes 

I am going to ask this boy how the print looks when he 
reads in his book. He replies that "it looks blurred." The 



A DEMONSTRATION CLINIC 93 

next boy says that the print " looks dark," but I am going to 
ask him what he means by "dark." He replies that he cannot 
see it, and I notice that he is troubled with what is technically 
called "squint eye," or crossed eye. Let us ask him if he ever 
sees letters or lines double. He says that a good deal of the 
time he does see letters and lines double, which is nearly al- 
ways the case in instances of this sort. Cases like this ought 
always to receive the promptest kind of attention, because 
the vision in the crossed eye deteriorates rapidly, and in 
many cases, if glasses are not properly fitted before the child 
is eight or nine years of age (or even earlier), the vision has 
already gone to the extent of fifty to one hundred per cent. 

I shall test this boy's vision right at this point, and see how 
much he still retains in the crossed eye. I have tested him by 
first standing away about twenty feet and holding up my 
fingers and having him tell me the number he sees. He fails 
absolutely at a distance of twenty feet; then he fails at a dis- 
tance of fifteen feet and he continues to fail until I get within 
nine feet of him. At this distance and in a strong light he 
can tell how many fingers are held up in front of the crossed 
eye. This shows that his vision has very greatly deteriorated 
in this eye. If glasses had been properly fitted to this boy's 
eyes several years ago, most of the sight could have been 
saved. This illustrates very well how absolutely necessary it 
is to correct the vision in any child who has a tendency to 
crossed eye. If the glasses are put on early the eyes will, in 
the majority of cases, be straightened without any operation, 
and most of the vision, if not all of it, will be retained. I have 
just asked the boy how long he has been wearing glasses. He 
is eleven years old and he says, "only a little while." The 
trouble is that the glasses were procured too late. 

I have just asked a little girl how the print looks to her, and 
her reply is that when she looks in her book she sees "two 
lines just the same." This is another case of "squint eye." I 
will also test her eyes in the same manner that I did the boy's. 
This child's vision is exactly the same as in the case of the 
boy. She reads fingers at a distance of about nine or ten feet. 

The next child that I question about her eyes says that 
the print "looks blurred, and runs all together." 

The next little girl replies when I question her about the 
print that "it blots," which is a perfectly characteristic 



94 HEALTH WORK IN THE SCHOOLS 

answer, given by a great many children in different places, 
and has a definite significance to anybody who understands 
the eye. 

The child now before me says the print "looks light," and 
by that she means that it appears dim and is not sharp and 
clear-cut. She probably has a case of astigmatism. 

Still another child replies that the print "looks crooked," 
which is also a very common reply. 

The next child has just told me what I suppose one hun- 
dred children at least have said. She remarks that the print 
"looks upside down." By that she does n't mean that it is 
actually upside down, but that it is turned around a good 
deal. 

This little girl now before me gives a very interesting and 
definite answer. She says, "The print looks like it was n't 
there and I am always skipping words." There is no ques- 
tion at all about the fact that she has a definite visual defect. 

The boy I am now questioning says the lines "look 
double." He has what we call "muscular unbalance." 

The next child says that after he has looked at the book a 
little while he sees "two lines instead of one." 

Another child says that some of the letters look big and 
some look small." 

This child whom I am now questioning gives another very 
interesting answer, which is definite and significant. He says 
that "some of the words look light, and some of the words 
look dark," which is just as clear a diagnosis of astigmatism 
as can be given by any doctor. 

The little girl now being questioned says that the words 
"look blotted, and some look lighter than others," and "I 
often mispronounce words, because I am not sure what the 
words are." 

The next child says, "When I study, the words all run 
together, and then it gets black." 

Here is a boy who tells me that he always reads the same 
line twice and he does not know why he does it, and when he 
reads at home in "magazines and things," he gets a head- 
ache. This is a very clear diagnosis of eye-strain. 

The next boy says "the words look dim and shaky." A 
great many children complain that the words move or jump. 

I will not repeat all of the remainder of the responses which 



A DEMONSTRATION CLINIC 95 

the children will give, but will pass on in the examination 
hurriedly. 

What I want you teachers to notice particularly is that, 
with two exceptions, all of the children of the eighteen ques- 
tioned give prompt and definite replies as to how the print 
looks to them, and that their answers give evidence that 
there is some real defect present. 1 Two of the answers were 
very vague, and the children merely repeated what they 
heard other children say. You can always be sure that in 
such instances there is little or no trouble. If a child has a 
visual defect that amounts to very much it can ordinarily 
be brought out by the sort of response which he gives to the 
question about his eyesight. 

Testing the vision 

We will now make a short demonstration of how to test 
the vision by use of the Snellen Test Card. 

In order to make this test, place the eye-test card in a 
good light, making sure that the child is not facing the 
light. Measure off a distance of 20 feet. Hang the card on 
the wall nearly on a level with the child's eyes. Cover one 
eye with a piece of cardboard or an envelope. Never allow 
anything to press on the eye, or it will interfere with the 
vision for several moments. Testing one eye at a time in this 
manner, ask the child to read the line on the card which is 
marked "20 feet"; that is, he ought to read the 20-foot line 
at a distance away of 20 feet. If he gets a majority of the 
letters, we pass him on the test. If he fails to get a majority 
of the letters, we ask him to take the next line, which he should 
read at 30 feet. If he fails to get the majority of the letters in 
this line, try him successively with each line above until you 
find a line which he can read. We will say, for example, that 
he reads the line which is marked "40 feet"; that is, it is a 
line which he ought to read at a distance of 40 feet, but as a 
matter of fact, he is only standing 20 feet away. Therefore 
his vision is 20/40, or one half what it ought to be. The dis- 
tance which the child is standing away from the card repre- 
sents the numerator of the visual fraction, and the line which 

1 These children had been selected by the demonstrator because 
all of them presented objective signs of visual defect. 



96 HEALTH WORK IN THE SCHOOLS 

he reads on the card represents the denominator. Children 
have a tendency to transpose letters, but this is of no conse- 
quence and no attention should be paid to it. If they are very 
slow in reading the letters, it usually indicates some eye 
defect, even though they read them correctly. 

I will now test the eyes of the boy who said a few moments 
ago that he often sees the letters double. I find that he does 
not see all of the letters in the 20-foot line and complains that 
they look blurred. He reads the 30-foot line without any 
difficulty, which gives him a vision of about 20/30. 

I am now testing another child who said that the letters 
run together. She reads the 30-foot line without any diffi- 
culty and a majority of the letters in the 20-foot line; appar- 
ently she only has a mild degree of eye defect. 

The next child reads a majority of the letters in the 20-foot 
line, but fails on one or two and says that they look slanting. 
Here, again, is apparently a rather mild degree of eye defect. 

This next little girl did not respond originally, but never- 
theless she has trouble. She cannot read the last line. She 
fails to read both the 20-foot and 30-foot line with the right 
eye, and testing her eyes with each line successively, I dis- 
cover that the 100-foot line is the first she can read. This 
little girl's vision is then about 20/ 100. The child says that 
the print looks all right to her when she is reading, but the 
teacher remarks that she always has to hold the book near 
her eyes. Of course she has a very high degree of eye defect, 
probably myopia, shortsight, and she ought to have glasses 
at the earliest possible moment, before the eyes deteriorate 
any more than they have already. 

In testing the vision of the young child who has not yet 
learned to read, it is best to make use of the McCallie test. It 
consists of a series of cards about 5 inches square on which 
are the pictures of a boy, a girl, and a bear. They are playing 
the game of ball, and the ball, which is represented by a small 
black dot, should be seen by the normal eye at a distance of 
20 feet. By changing the cards frequently it is easy to dis- 
cover whether or not the child can really determine who has 
the ball. If he does not see the dot at a distance of 20 feet, 
then you gradually walk toward him until he succeeds in 
seeing it and then you estimate from this about what his 
visual error is. 



A DEMONSTRATION CLINIC 97 

Other eye dejects 

Teachers ought not only to observe and record defects of 
fc vision, but ought also to make note of congested eyes, watery 
eyes, sties, and granulated lids. None of these conditions are 
normal, and all of them should receive attention. The seri- 
ous eye disease known as "trachoma" is contagious, and 
very difficult to cure. It is observed chiefly among children 
from the slums who have recently arrived from Europe. It 
is also rather common among the Indians and Japanese. 
It is difficult for any but an expert to recognize this disease, 
but one should suspect it when any children of the class in- 
dicated above have eye conditions described as follows : — 

(1) Inflammation: this is not very intense, but there is 
considerable swelling of the lids, an aversion to light and a 
flowing of tears. 

(2) The outer surface of the eyeball becomes roughened. 

(3) The inner surface of the eyelids is covered with small 
granules not unlike boiled sago grains in appearance, and 
this produces what is called granular eyelids. 

A sudden redness of the eyes, with more or less sensitive- 
ness to light, particularly when accompanied by what ap- 
pears to be a cold, should always cause the suspicion of 
measles. Sometimes pink-eye starts in this manner. 

Adenoids 

I want to show you now how easy it is to detect the chil- 
dren who are suffering from adenoids. I can go through any 
room and in most instances can detect nearly all the adenoid 
children within two or three minutes after I have been in the 
room, and what 1 can do the teacher ought to be able to do 
just as easily, because she is perfectly familiar with the chil- 
dren. I shall select a boy whom I have never seen before, 
a boy who looks to me as if he had adenoids. Then we will 
test him to see if he really has them. My first reason for se- 
lecting this boy is because he has a tendency to breathe with 
his mouth open. In making the examination I note at once 
that the lower teeth cut considerably inside the upper teeth 
and that the upper teeth are prominent, which is very often 
the case where a child has breathed through his mouth for 



98 HEALTH WORK IN THE SCHOOLS 

one year or more. In other words, mouth-breathing has a 
tendency to deform the jaws, so that the teeth in the upper 
jaw are either crooked or prominent, or both. Or, to put it 
another way, probably in ninety -five per cent of all the cases 
where one notes crooked and prominent teeth, mouth-breath- 
ing has occurred. Adenoids tend to produce more or less 
deformity of the bones of the face. Thumb-sucking and the 
early loss of the first teeth also have a tendency to produce 
crooked teeth and other deformities of the jaws. 

The first thing that I am going to do in testing this child is 
to ask him to talk a little, because I want to discover the 
quality of his voice. The boy's voice proves to be distinctly 
nasal in quality, and by giving these words which you have 
just heard him pronounce, "nine," "ninety-nine," "nine 
hundred and ninety-nine," you at once bring out this nasal 
quality of the voice. Now there are in general only two rea- 
sons why a child has a nasal voice. One is that he has an 
acute cold, and the other is that he has an obstruction in his 
nose, usually due to adenoids. This boy has no cold; so rea- 
soning from what I have said, he has adenoids. And you can 
be sure in practically every case that, barring a cold, a nasal 
voice in a school child means just one thing, and that is ade- 
noids. If in addition to this you can discover that the child 
sleeps with his mouth open and has a tendency to snore, you 
may be quite sure that you have a case of adenoids. I have 
just asked this boy if he snores in his sleep and he says, 
"Yes." His mother tells him that he does. 

In reply to my question as to how his mouth feels when he 
wakes up in the morning he says that his "mouth feels dry," 
and the reason, of course, is that he has breathed all night 
with his mouth wide open. Mouth-breathing is never nor- 
mal. 

The next boy I have selected for examination says that he 
has had an operation on his nose and throat, and as a matter 
of fact I note that the tonsils have been removed. Probably 
the adenoids were also removed, but in any event there is 
some adenoid tissue still present. The adenoid tissue may 
not have been completely removed or it may have returned, 
because not infrequently adenoids come back a second, and 
sometimes even a third time. There is only one thing to do 
in these cases, and that is to have the operation repeated and 




£0*O\OS 



Why adenoid children cannot breathe. 




Three views of an adenoid face. 
ADENOIDS 




CROSSED EYE AND OBSTRUCTED BREATHING 
Courtesy Dr. N. H. Bullock, San Jose\ Cal. 



A DEMONSTRATION CLINIC 99 

all the tissue removed. This child's facial bones have been 
somewhat deformed by mouth-breathing before his opera- 
tion. 

Hearing, and ear troubles 

Teachers ought always to be suspicious of ear trouble 
where there are adenoids, because adenoid tissue has a tend- 
ency to cause trouble with the ears. For this reason I am 
going to test this boy's hearing, to see whether or not it is 
good. I suspect that he is somewhat deaf, because he has 
already asked me to repeat questions a number of times. To 
test the hearing, one of the best ways is to use the watch. You 
want to determine how far you can hear your own watch in a 
certain room. You cannot state in advance how far a watch 
ought to be heard. Sometimes people say to me, "How far 
should a watch be heard?" Of course, it goes without saying 
that it depends upon the watch, and upon the room in which 
you are giving the test. To determine this point, take your 
own watch in a given room and see how far you can hear it, 
making sure that your own hearing is good to begin with; 
then let this distance be used as the norm. I can hear my 
own watch in this room at arm's length, which is close to 
two and a half feet. In testing the hearing, always cover the 
child's eyes with one hand. This boy's hearing is reduced in 
his right ear a little more than one half. In making the test 
be sure that the child is not drawing on his imagination, and 
in order to determine this point occasionally hold the watch 
behind you and ask the child if he hears it. The hearing in 
the left ear proves to be about two thirds normal. 

The boy says that he has never had scarlet fever, nor, as 
far as he knows, any serious sickness. This is pretty good 
evidence that the defective hearing is not due to any acute 
infectious disease, as is sometimes the case, and that the de- 
crease in hearing is due entirely to adenoids. This is cer- 
tainly an illustration of the fact that adenoids ought to be 
taken care of early. In a very large number of cases adenoids 
result in seriously defective hearing. Every child with ade- 
noids ought to have his ears examined. Every child who has 
earache or running ears ought to be examined for adenoids. 
In other words, nearly all the ear trouble in children origi- 
nates in the nose and throat. The trouble is not primarily 
in the ear, but in the nose and throat. Sometimes it is be- 



100 HEALTH WORK IN THE SCHOOLS 

cause the adenoid tissue which is situated behind the soft 
palate grows over the opening of the eustachian tube, which 
as you know leads to the middle ear and ventilates it. 
Sometimes the ear trouble results from a catarrh of the nose 
and throat, due either to adenoids or diseased tonsils, and 
the inflammation travels through the eustachian tube to the 
middle ear and sets up a similar inflammation here. So never 
forget that there is a very close and intimate relation be- 
tween ear troubles and those of the nose and throat, and 
that most ear defects are avoidable. 

The whisper test of hearing 

If you ever have any reason to suspect that the answers of 
a child are incorrect, when he is being tested with the watch- 
tick, it is a very easy matter to test him with the whispered 
voice. Place him at least twenty feet away, cover your own 
lips with a piece of paper, so that he cannot see their move- 
ment, and then give him commands in a whisper. If he fails 
to execute the commands you may be perfectly sure that he 
does not hear well, provided a normal child already tested at 
the same distance does execute the same commands when 
you use the same intensity of whisper. It is always a good 
procedure to use both the watch and the whispered voice 
test. In the main it is safe to say that eight per cent of the 
children in schools have adenoids, that five to seven per cent 
of the children are partially deaf when tested with rough 
methods, and that nearly fifteen per cent of them would be 
found to have defective hearing if they were accurately tested 
by a physician. I want to repeat here that almost all of this 
trouble is due to neglected adenoids or diseased tonsils. 

The teeth 

In examining the teeth of children, stand in a good light 
with your back toward the window, and have the children 
form a line. Let them march past you, and as each child 
comes in front of you have him open his mouth just as wide 
as possible. Put one hand on the top of the head and the 
other on the chin, and the mouth will open wide. Note 
whether or not the child has any bad teeth, and if he has, 
make a record of it. It is a general impression among par- 



A DEMONSTRATION CLINIC 101 

ents and teachers that it is all right to ignore defective teeth 
in young children, — i.e., the baby teeth, — but as a matter 
of fact it is more important to get the first, or deciduous, 
teeth repaired than it is the permanent ones. So any de- 
cayed teeth, whether in a young child or in an older one, 
ought to receive prompt attention. 

General health survey 

Having demonstrated these simple procedures in testing 
the eyes, ears, nose, and teeth, we will now make a general 
health survey of the children, by asking some questions. 

"How many children here have a good deal of headache? 
By that I mean as often as once a week, or three times a 
week, or every day? " Eight children respond to this ques- 
tion and complain of more or less chronic headache. This is a 
smaller number than we usually discover. There are eighty- 
five children present, and out of that number we should ex- 
pect to find fifteen or twenty who suffer more or less from 
chronic headache. 

"How many children here have earache every once in a 
while? " Now the number standing is just about what we 
should expect to find. We have ten children standing, which 
is about the usual proportion. 

"How many of you children sometimes have running ears? 
Do you ever come to school with pieces of cotton in your 
ears? " In this group there are no children who complain of 
running ears. Ordinarily we find about four per cent. 

"How many children often have toothache? " Seventeen 
children complain of more or less toothache. It is well to 
remember that a sound tooth never aches, although it is also 
true that some decayed teeth do not ache. So you can be 
sure that every child who has aching teeth has unsound teeth, 
but you cannot be sure that every child who does not com- 
plain of aching teeth has sound teeth. 

"How many children here have a toothbrush at home?" 
Thirty-six of the eighty-five present reply that they have. 

"How many use your toothbrush every day?" Only seven 
reply that they do. Unless a child uses his toothbrush regu- 
larly you may be perfectly sure that he does n't use it much, 
if any. It is one thing to have a toothbrush, but quite an- 
other thing to use it, and particularly to use it correctly. 



102 HEALTH WORK IN THE SCHOOLS 

"How many of you have a toothbrush that is all your own, 
that nobody else uses? " The answer indicates that there are 
about three "common " toothbrushes. This is a smaller pro- 
portion than we usually find. We generally discover about 
five to ten in every hundred children who use the "family" 
toothbrush. 

"How many children always have the bedroom window 
open at night, even in cold weather?" Sixty-five of the 
eighty-five present do not have ventilated bedrooms when 
the weather is cold. 

How many children have ever been to a dentist? " Only 
twenty-eight out of eighty-five have been to a dentist at 
some time. The rest apparently have never been at all. 

"How many of you children drink coffee?" Sixty-eight 
reply that they do. The proportion is usually about seventy- 
five per cent. 

"How many of you always eat some fruit for breakfast? " 
Eighteen out of eighty-five respond that they do. The re- 
mainder apparently do not, and yet fruit in some form is a 
most important article of diet for the child. 

"How many children here always have some meat or some 
eggs to eat for breakfast? " About four fifths of the children 
are standing. Usually we discover that over half of the chil- 
dren eat starchy breakfasts of a most inadequate nature. 

Physiological and chronological age 

At this point I would like to call your attention to the fact 
that we have in the schools a very considerable number of 
pupils in whom there is a great discrepancy between the 
physiological and chronological age. Under-developed chil- 
dren are often immature in mental as well as physical make- 
up, and for this reason they are prone to exhaustion and 
early neurasthenia when subjected to the same school strains 
which stronger and more mature children of the same actual 
age can easily withstand. Teachers and parents should give 
careful attention to the physiologically immature child, for 
they may in many instances save such from serious conse- 
quences in later life. 

Please observe the group of pupils now standing before you. 
There are five children, all eleven years of age, but physio- 



A DEMONSTRATION CLINIC 103 

logically there are apparently great differences present. 
Between the largest and the smallest child here there is a 
difference of over forty pounds in weight and eight inches in 
height, to say nothing of differences in muscular strength, 
lung capacity, general endurance, etc. These children are 
all expected to do exactly the same school work, but it is 
evident from the most superficial examination that some of 
them are relatively weak and immature. The smallest child 
in this group has to my personal knowledge, a definite neuro- 
sis at this very moment. 

Summary of the observations 

Now, to make a rapid summary of what we have discov- 
ered here, by a few very simple questions : We note that of 
85 pupils, 16 apparently have definite defects of vision; 5 
have chronic earache; none complain of running ears; 8 have 
chronic headache; 17 have frequent toothache; 57 have never 
been to a dentist; only 38 have toothbrushes of their own, 
and of these but 7 use them every day; there are 3 "com- 
mon," or "family" toothbrushes; 65 have unventilated bed- 
rooms in cold weather; 67 have no fruit for breakfast; about 
one fifth have no proteid food for breakfast; and 68 drink 
coffee. 

In addition to the points which have been brought out in 
this demonstration clinic to-day it is easy for the teacher to 
make observations in respect to the following conditions : — 

Frequent sore throat. 

Malnutrition. 

Nervous disorders. 

Deformities. 

Defective postures. 

Glandular enlargements in the neck. 

Goitre. 

Skin diseases. 

Early contagious disorders. 

Hygiene teaching 

[At this point the children were dismissed and the rest of 
the talk was addressed to the teachers.] 



104 HEALTH WORK IN THE SCHOOLS 

This little questionnaire not only brings out the existence 
of a very considerable number of physical handicaps, but 
ought to aid you very materially in discovering what sort of 
hygiene teaching is most needed with a given room of pupils, 
and I would recommend it to you particularly for this pur- 
pose. It is of no particular use to teach children about things 
which are = not related to their daily lives, but by such a 
series of questions you can find out almost exactly what 
things they most need to know in respect to their personal 
health. If a child suffers from earache, or if several children 
suffer from earache, the rest of the group in the room will be 
interested and some teaching on the subject of earache will 
be effective. The same may be said of toothache, visual de- 
fects, and the other things which we have mentioned. 

Notifying parents 

A word now about how to get a response from the parent, 
after the teacher has discovered that physical defects are 
present. A blank notice ought to be used, such as is found in 
the little survey which the Minnesota State Board of Health 
furnishes free to teachers. The notice reads as follows: 

" appears to the teacher to be in need of 

attention. A further examination by your family physician, 
dentist, or specialist, is advised." Now, you see that the 
notice simply says "appears to," and consequently does not 
definitely commit the teacher. This notice is signed by the 
Principal of the school, or by the Superintendent. The 
teacher simply writes in whatever she thinks is wrong with 
the pupil. In the majority of instances you will find that the 
notice receives no attention whatever on the part of the par- 
ent, and this is one great difficulty that teachers complain 
about in respect to this health work that they are asked to 
carry on. Parents seem to be quite indifferent to the physical 
handicaps of their children. However, this is only an appar- 
ent indifference. The real difficulty is that the parent does 
not understand the significance of the conditions found in 
the child. A parent does not appreciate that adenoids have 
serious consequences. He does not know that there is any 
relation between aching and discharging ears and adenoids, 
or between adenoids and crooked, prominent teeth and reced- 



A DEMONSTRATION CLINIC 105 

ing chin, or between adenoids and catarrh, or between en- 
larged, diseased tonsils and rheumatism, or between visual 
defects and headache and nervousness, and so on indefinitely. 
Now what the parent really needs is some simple information 
along these lines. When once he really understands the situ- 
ation, in almost every case he will cooperate. I have found 
this to be the case by long experience in work with school 
children. In order to give the parent the kind of instruction 
which he requires, I think the best plan is to send with the 
notice which the child takes home a little pamphlet which 
describes in very simple language what the defect is, and 
what the consequences of such a defect are when neglected. 

Mentally peculiar and defective children 

Exceptional children of various types have been in our 
schools since schools began, but only within the past few 
years has any systematic attempt been made to recognize 
and classify them. Indeed, such recognition and classifica- 
tion was almost impossible until psychologists developed 
practical, direct methods for the use of schools. Teachers 
have always been able to point out some "fools" in their 
classes, and other types of exceptional children have been 
vaguely recognized, but "fools" have been present who were 
thought to be merely slow or dull; "misfits" who were sup- 
posed to be "fools"; dullards who were considered "mis- 
fits"; and so on indefinitely. It remained for the psycholo- 
gists to devise methods whereby these various types might 
be studied and classified, and among these must be particu- 
larly mentioned Witmer and Goddard of this country, and 
Binet in France. 

In 1905 Binet and Simon, of Paris, first published their 
tests, now popularly known as the "Binet Scale," and in 1908 
and 1911 they still further developed and improved this 
method. These tests have from time to time been modified, 
enlarged, and improved by various other psychologists, 
including among others Goddard of Vineland, Kuhlmann of 
Faribault, and Terman of Stanford. 

The Binet method still leaves much to be desired, but is 
nevertheless serving to stimulate teachers as they have never 
been stimulated before to make careful observations of the 



106 HEALTH WORK IN THE SCHOOLS 

unusual types of children under their care. According to 
recent investigations, and especially those of Goddard, from 
1 to 3 per cent of the children in our public schools are 
mentally defective, and this in spite of the fact that they 
are frequently unrecognized as such by either their parents 
or teachers. Such children often present no physical signs of 
such defectiveness and may indeed be among the best- 
looking children in a grade. Sooner or later, however, chil- 
dren of this type become retarded, and attention is thus 
called to them. A safe rule for teachers to follow is that 
every child who is retarded in school two or more years with- 
out evident reason should be suspected of possessing some 
degree of mental defectiveness. Not every child who is thus 
retarded is feeble-minded, but proof to the contrary should 
at least be established before the child is removed from sus- 
picion. Degrees of feeble-mindedness are present among 
school children, varying all the way from low grade imbecil- 
ity to the condition of the high-grade feeble-minded person 
known as the "moron," who is just below the line of nor- 
mality. 

For example, I recently examined a girl of fourteen who 
had been in the first grade for five successive years, and it 
soon became apparent that she had a mentality of about 
three years. Beyond this degree of intelligence there is no 
reason to believe she will ever pass. Another child had a 
chronological or actual age of fourteen and a mental age of 
eight and one half. This boy may perhaps develop to a men- 
tal age of a normal child of nine or ten years, but not much 
beyond this. Still another pupil had an actual age of sixteen 
with a mental age of only nine. Another was twelve years 
old with a mental age of seven. In every one of these cases 
the teacher knew, of course, that something was wrong, for 
all were retarded in school, but that it was true feeble- 
mindedness was never suspected except in the first instance, 
and even here it was not understood by parent or teacher 
that the child was practically non-educable. On the other 
hand, a boy of fourteen was considered feeble-minded by his 
teacher when he was only a misfit. 

Every village and city school system which I have visited 
has produced cases of retarded, feeble-minded children, and 
where there was time to make any sort of adequate study of 




CHRONOLOGICAL AND PHYSIOLOGICAL AGE 

These five children are all eleven years old. 



A DEMONSTRATION CLINIC 107 

the question the proportion has appeared to be just about 
that estimated by Goddard, viz., 2 per cent. 

The following types of exceptional children require careful 
attention on the part of teachers: (1) Retarded children 
(especially those retarded two or more years) ; (2) slow chil- 
dren (not necessarily retarded); (3) precocious children 
(especially those who are delicate); (4) delinquent children; 
(5) misfit children; (6) highly nervous children. 

In order to decide whether a child is actually deficient in 
mentality, some competent teacher in every school system 
should familiarize herself with the Binet method for measur- 
ing the intelligence of children. Such a teacher need not be 
expected to become an expert or to obtain very exact results, 
but she may at least in the majority of cases arrive at a con- 
clusion which will establish the fact of feeble-mindedness or 
normality. The exact degree of feeble-mindedness present in 
a child is a matter for a clinical psychologist or school medi- 
cal officer to determine, but this, though desirable is not 
always indispensable knowledge in the practical classifica- 
tion of school children. 

[Eight retarded children were now called into the room 
and arranged in a line, with a ninth standing in front of them. 
It was recommended that in each case the actual mental 
age ought to be determined by the Binet scale. These chil- 
dren gave their ages and grades as follows : — 



1 


13 years 5th grade 


2 


12 


4th 


<i 


3 


13 


4th 


<< 


4 


13 


5th 


H 


5 


13 


5th 


<< 


6 


13 


5th 


« 


7 


12 


4th 


« 


8 


14 


5th 


« 


9 


9 


2d 


<< 


A subsequent 


examination proved that only two of these 


children had a 


mental age 


equal to their actual i 


age.] 



Children who are merely dull will not and cannot receive a 
great deal of education, but their judgment is usually not 
bad. We should not try to educate these pupils too much. 
They will succeed fairly well in the world along lines not 



108 HEALTH WORK IN THE SCHOOLS 

requiring superior intelligence. The mentally defective child, 
on the other hand, has defective judgment as well as defec- 
tive intelligence. He does not profit by the ordinary kind of 
school education at all. Either the school must provide 
special lines of work for him, or else he must be sent to an 
institution for defectives. Children nine years of age or less 
who are mentally retarded as much as two years, and chil- 
dren from nine to thirteen who are retarded as much as 
three years, do not ordinarily belong in the public schools. 
They should be kept in state institutions for the feeble- 
minded. Few who are retarded this amount can be made 
self-supporting. 

A word of caution is required. Do not depend upon the 
Binet or any other method exclusively. Use common sense. 
Do not disregard ordinary school methods of judgment. Do 
not regard the Binet Scale as one which can be used with the 
absolute certainty of a measuring stick. Make use of any and 
all methods available in the estimation of the intelligence of 
exceptional children. Finally, regard your conclusions in 
most instances as tentative, and carefully watch the develop- 
ment of each case. 

The other types of children mentioned, viz., the dull, pre- 
cocious, nervous, and misfit, require as careful study as the 
feeble-minded. Indeed, they deserve perhaps more atten- 
tion, because these are the types which under proper disci- 
pline make satisfactory progress and may be saved years of 
unnecessary sorrow and ineffective effort. 

Professor Terman's handbook for the study of excep- 
tional children, containing the most accurate revision of the 
Binet Scale which has yet been made, will be issued about 
January, 1915. It will give special attention to the simplifi- 
cation of the directions for applying the Binet method so 
that it may be used by any teacher. 



5S 














Granite 
Falls 


Pipestone 


Albert Lea 


Waseca 


Windom 


Wabasha 




April 18 


- 


- 


- 


- 


- 




8, 4, 5 


4, 5, 6 


3, 4, 5 


- 


3, 4, 5 


3, 4, 5 


Average 
per cent 


9,1 


114 


85 


- 


94 


52 




39 


3 


65 


- 


31 


31 


3? 


84 


102 


36 


- 


94 


38 


81 


19 


oo 


7 


- 


37 


18 


19 


2 


8 


3 


- 


12 


3 


9 


X 


48 


57 


- 


X 


26 


50 


28 


30 


17 


- 


X 


14 


28 


26 


28 


8 


- 


25 


13 


25 


1G 


37 


1G 


- 


17 


12 


22 


13 


19 


5 


- 


7 


14 


13 


4 


7 





- 


4 


3 


4 


X 


36 


X 


- 


X 


X 


15 


6 


X 


7 


- 


X 


X 


6 


X 


X 


5 


- 


X 


X 


5 


X 


32 


17 


- 


46 


20 


33 


84 


95 


67 


- 


91 


41 


82 


54 


82 


68 


- 


X 


40 


71 


ted on the I 


>asis of the 


number of p 


upils questi 


oned in eacl 


i case. 





TABLE II. SCHOOL CLINIC 



A SUMMARY OF CLINICS HELD AT SIXTEEN CITIES 



Date .... 
Grades . . . 
Number present 



No ventilation of bedroom .... 

Own a toothbrush 

Daily use of toothbrush 

Use of common toothbrush .... 
Never have been to a dentist . . . 

Frequent toothache 

Frequent headache 

Blurred vision 

Frequent earache 

Running ears 

Frequent sore throat 

Adenoids 

Diseased tonsils 

No form of proteid food for breakfast 

No fruit for breakfast 

Daily use of coffee . 



Adrian 



May 7 

3-8 inc. 

95 



Luverne 



May 7 

3, 4, 5 

44 



26 

39 

10 

4 

19 

9 

13 

16 

6 

1 

x 

6 

3 

19 

40 

25 



Dawson 



April 23 

3, 4, 5 

107 



83. 



Winthrop 



April 20 

2-5 inc. 

87 



57 

82 

14 

10 

x 

41 

37 

19 

13 

4 

5 

6 



96 



Madison 



April 24 

2-5 inc. 

119 



Benson 



April 11 

4, 5 & 7 

113 



40 
104 



15 



104 



3-5 inc. 
91 



32 



Morris 



April 8 

4&5 

22 



Granite 
Falls 



April 16 


April 22 


April 18 


3&4 


4&5 


3, 4, 5 


65 


89 


95 


X 


5 


39 


57 


80 


84 


22 


40 


19 


X 


X 


2 


X 


X 


X 


17 


20 


28 


13 


X 


26 


7 


20 


16 


16 


12 


13 


3 


4 


4 


6 


X 


X 


3 ■ 


4 


6 


4 


X 


X 


16 


X 


X 


50 


X 


84 


33 


40 


54 



Pipestone Albert Lea 



4, 5, 6 
114 



3 

102 
22 



30 

28 
37 
19 
7 
36 



3, 4, 5 

85 



65 
36 

7 

3 

57 

17 

8 

16 

5 



x 

7 

5 

17 

67 

68 



3, 4, 5 



31 
94 
37 
12 



46 
91 



3, 4, 5 

52 



31 
38 
18 
3 
26 
14 
13 
12 
14 



Average 
per cent 



37 

81 
19 
9 
50 
28 
25 
22 
13 



3 


4 


X 


15 


X 


6 


X 


5 


20 


33 


41 


82 


40 


71 



x Blank spaces indicate that the question was not asked, or examination was not made. The percentages in the last column are, of course, estimated on the basis of the number of pupils questioned in each case. 



CHAPTER VII 

THE SCHOOL MEDICAL CLINIC 

Difficulty of getting results from medical inspection 

Dr. H. H. Hogarth, assistant medical officer of 
Education for the London County Council, has made 
an observation in his excellent book on the Medical 
Inspection of Schools to the truth of which all experi- 
enced school doctors will assent. "Every school doc- 
tor," he says, "goes through the same process of 
reflection and education. At first he enters the school 
as a novice, recognizing that his duty is to inspect, not 
to treat ; that his own position is open to attack on the 
part of his brother practitioners; that he may be inter- 
fering with the rightful responsibilities of parents. He 
is so absorbed in the new work, the new ideas; so inter- 
ested in the children, the educational system, and the 
teachers, that as soon as he has notified parent and 
teacher that a child is suffering from some particular 
disease, leaving them to take whatever further action 
may be necessary, he considers he has done his part. 
It is not until he returns a year later that he realizes 
how completely his advice has been ignored. Then he 
begins to think." 

As has already been emphasized, medical inspection 
in the beginning was little more than inspection. The 
early New York inspectors found that ninety-four per 



110 HEALTH WORK IN THE SCHOOLS 

cent of their notifications failed to bring results. In 
England, likewise, where poverty is more widespread 
than with us, the results were so disappointing as to 
awaken everybody concerned to a realization of the 
futility of any system of inspection which takes no 
steps to ameliorate the evils it discovers. 

Casting about for means to accomplish this end, 
school authorities have discovered a number of reme- 
dies of various degrees of effectiveness. One of these 
is the system of school nurses, already discussed. An- 
other remedy, supplementary to school nursing, and 
of even greater portent for preventive medicine, is the 
school clinic. 

What the school clinic is 

The school clinic is a clinic controlled by the educa- 
tional authorities, and supported at public expense for 
the purpose of permitting a more thorough examina- 
tion, and in some cases also treatment, of defects re- 
vealed by the routine inspection. In many cities the 
work of the clinic is confined to the first of these func- 
tions. The school doctor on his rounds finds children 
whose condition merits a more thorough diagnosis than 
can be given in the preliminary and rather superficial 
survey. The parents of such children are asked to 
bring them to the clinic for special examination and 
advice. If grave defectiveness or disease is found, the 
parents are urged to secure the necessary treatment 
from the family physician, or in case of extreme pov- 
erty the school doctor may arrange with local hospitals 



THE SCHOOL MEDICAL CLINIC 111 

or dispensaries for gratuitous service. Clinics for this 
diagnostic and advisory purpose have everywhere 
rapidly followed the introduction of medical inspec- 
tion. In cities above 15,000 or 20,000 population they 
are fast coming to be looked upon as a standard re- 
quirement of any system of school medical service. 

The main purpose of this chapter, however, is to 
describe a somewhat different type of school clinic, 
already becoming numerous in England and not un- 
known in the United States, — a clinic designed to 
afford more or less treatment as well as diagnosis. 

Typical school medical clinics of England 

Dr. Lewis Williams' account * of the school clinic at 
Bradford, England, gives an excellent idea of the sig- 
nificance of this new medico-educational institution. 
Bradford is a manufacturing city of about 300,000 
population. The school clinic was opened about two 
years ago, in the hope that it would make possible the 
treatment and cure of that large percentage of children 
who, because of indigence or parental neglect, had 
received no benefit from the inspection of their defects. 
The staff consists of three physicians, one dentist, two 
nurses, and two clerks, all on full time. Treatment is 
free, except that parents, when able, are required to 
pay the actual cost of eye-glasses. Although attend- 
ance is voluntary, objection to treatment is very sel- 
dom met with. The reason for this lies partly in the 
absence of expense, but perhaps still more in the psy- 
1 See reference 5, at the end of this chapter. 



112 HEALTH WORK IN THE SCHOOLS 

etiological difference between persuading parents to do 
something and merely securing their consent to have 
it done. The former violates the principle of human 
inertia; the latter takes advantage of it. The following 
table shows what the Bradford clinic accomplished in 
1910: — 

Number treated 

Defective vision 650 

External eye disease 576 

t>. f of head 623 

Ringworm | ofbody ^ 

Verminous heads 360 

Scabies and impetigo 419 

Ear discharge 285 

Defective teeth 450 

Stammering 150 

Infectious disease 1052 

Of the 5000 who secured free treatment at the clinic, 
certainly very few would have received any other atten- 
tion whatever. Ringworm of the head was treated by 
the X-ray method, one exposure being sufficient in over 
92 per cent of the cases. At a cost of from 30 to 65 
cents each, 559 pairs of glasses were supplied. A spe- 
cial teacher was employed to give breathing exercises 
and other treatment to stammering children. 

In 1908, a clinic was opened in the Poplar School, 
London, organized by Miss Margaret MacMillan and 
endowed by Mr. Joseph Fels. This is interesting as 
showing what can be accomplished by a small clinic, 
drawing its cases from only about 1000 children of a 
single school. 1 During the two years from December 
1 See article by Dr. Tribe, in School Hygiene for May 1911. 



THE SCHOOL MEDICAL CLINIC 113 

1908 to December, 1910, 450 pupils came under treat- 
ment in this clinic, or nearly half the total enrollment 
of the school. An analysis of 210 of the 450 cases shows 
a number of interesting facts. Twenty-three cases 
were treated daily for ear discharge, until cured. On 
the average, the number of months required to cure a 
discharging ear about equaled the number of months 
the ear had been neglected. The clinic recommended 
35 cases of adenoids or enlarged tonsils for operation, 
and out of this number met only two refusals. Fifty- 
five children were treated for anaemia or debility, of 
whom 32 were either cured or distinctly improved. Of 
the 210 cases analyzed, cure was effected for 94, 21 
were improved, 67 were still under treatment when the 
report was made, 8 had been transferred to a hospital, 
and 9 had left school. All of this was accomplished 
with no interference in attendance, and at slight ex- 
pense. 

Similar school clinics have been established in Eng- 
land in many other cities. 

Cost, equipment and management 

Hogarth estimates that $7500 will usually suffice to 
build and equip a clinic for a city of 20,000 population, 
counting $2500 for equipment and $5000 for building. 
It should provide five or six rooms, as follows: One 
large and one small waiting-room, two consulting- 
rooms (for physician and dentist), a dark room, and a 
nurse's room. For a large staff more room will be re- 
quired. The staff should include an oculist, a general 



114 HEALTH WOEK IN THE SCHOOLS 

physician, a dentist, nurses, and assistants. In small 
cities the staff is usually composed of regular practicing 
physicians, who receive official appointments to devote 
from one to three half -days per week to the work. The 
customary remuneration is about $5 for each half- 
day of work. Some of the larger clinics, like that of 
Bradford, employ all the physicians on full time. Dr. 
Williams thinks full-time employment preferable, wher- 
ever it is feasible. The physicians become more inter- 
ested in their work, and come to see more clearly its 
educational bearings. Another practical advantage of 
this plan is that it is less likely to create friction between 
the school physician and local practitioners. When the 
school physician also engages in practice he is likely 
to be suspected of using his office to secure patronage 
for himself. 

Why free clinics are necessary 

The policy of free medical and dental clinics sup- 
ported by public taxation differs in no respect from 
the universally accepted principle of public education. 
The latter, in effect, presupposes the former, inasmuch 
as children with neglected physical defects cannot re- 
ceive in full the benefits which the school has to offer. 
It would be folly to permit any a priori social theory to 
blind us to the essential facts. 

At the risk of repetition let us review some of the 
obstacles encountered in the process of education and 
of medical inspection which have led to such an unfore- 
seen and radical departure from our ancient moorings. 



THE SCHOOL MEDICAL CLINIC 115 

The most important and common defects and dis- 
eases revealed by medical inspection are defective vis- 
ion, discharging ears, adenoids and hypertrophied ton- 
sils, tuberculosis, enlarged glands, carious teeth, and 
malnutrition. The purpose of medical inspection being 
to combat racial degeneracy and to conserve vitality, 
its sole justification lies in the contribution it makes to 
this end. This may sound trite, but it is fundamental. 
The following are illustrations of the difficulties met in 
the accomplishment of this purpose. 

Discharging ears, as has been shown, present a con- 
dition of great seriousness, and need in most cases to 
have daily attention, such as syringing, washing, etc. 
Now experience proves that usually parents will not, 
even when urgently and repeatedly advised by the 
school doctor or nurse, secure for the child so afflicted 
the proper medical care. As a rule they lack the knowl- 
edge of hygiene and medicine which would enable them 
to appreciate the situation. Others, and these are very 
numerous, canot afford the services of expert oculists 
or aurists at current rates, and are reluctant to accept 
as charity what they have not the means to command. 
Even when the aurist is consulted for a discharging 
ear, the tedious treatment which ensues, often lasting 
many months, is seldom carried out by parents with 
the needed regularity and carefulness. Physicians find 
that in most cases it is simply folly to expect a cure by 
this method. The only assurance of success in this 
direction is for the child to be taken daily to the physi- 
cian's office or to the hospital for the necessary treat- 



116 HEALTH WORK IN THE SCHOOLS 

ment. Aside from the question of expense or the preju- 
dice against charity, it is useless to expect that this will 
be done. Each visit may consume from two to four 
hours of time. Whether rich or poor we are too busy 
and impatient to submit to such a tedious ordeal. The 
result is that nine tenths of the cases of ear discharge 
among school children have been neglected. Theorize 
as we may about the danger of tampering with parental 
responsibility by the support of school clinics for free 
treatment, we are confronted by this fact of neglect. 

With the inauguration of the school clinic the entire 
problem vanishes. The child goes daily to the near-by 
clinic, often in the building where he attends school, 
and receives the necessary treatment at the hands of 
nurse or doctor. There is no waste of time, no loss of 
school attendance, and a mere bagatelle of expense. 
Best of all, the treatment brings cure. 

Most of the other forms of defectiveness offer, 
with greater or less variation, the same problems and 
the same solution. In the case of defective vision, for 
example, to secure parental action requires, in about 
50 per cent of the cases, from two to four home visits 
by the school nurse. In the case of 15 to 30 per cent, 
nothing is ever accomplished. Many who respond do so 
by seeking the inexpert advice of opticians. Now and 
then a parent buys a pair of ten-cent goggles from a 
street peddler and thinks that in this sacrifice he has 
paid due homage to Hygeia. A small minority take 
their children to a reputable oculist and have them cor- 
rectly fitted with glasses, at an expense of $5 to $30 



THE SCHOOL MEDICAL CLINIC 117 

each. Only a very small minority, be it said to the 
credit of humanity, seek for or permit assistance 
through laws for relief of the poor. The sum total of 
results is disappointing, notwithstanding the cost in 
time and energy. Upon the establishment of the 
school clinic of the English type the situation is com- 
pletely changed. When a child is discovered with de- 
fective vision, instead of hounding the parents with 
arguments and pleadings, the child is sent to the clinic 
and is tested for glasses. The clinic even secures for 
the child necessary lenses and frames at special rates, 
arranged for by the school authorities with a reliable 
optician. The cost ranges from 30 to 60 cents, and is 
met by the parents, if they are able; if not, by the 
school board. In English cities, such as Bradford, 
about 80 per cent are paid for by the parents. But the 
important points are that the eyes actually receive 
treatment, that the treatment is skillful, and that the 
cost is inconsiderable. 

In like manner, enlarged glands, tuberculous ten- 
dencies, throat occlusions, and many other defects re- 
quire either more expert or more constant attention 
than they are likely to receive from the family doctor. 
The X-ray treatment for ringworm is a good illustra- 
tion of the efficiency that may be secured by the intro- 
duction of wholesale methods into medical practice. 
Only a few practitioners have the equipment for treat- 
ment; those who have it charge high fees, while the 
disease is common only among the poor. Left to such a 
combination of circumstances the disease would flour- 



118 HEALTH WORK IN THE SCHOOLS 

ish indefinitely. The properly equipped school clinic 
practically eradicates it from a middle-sized city within 
a few months, and at an expense which is almost neg- 
ligible. 

By the old way everything had to be done with a 
maximum of inconvenience, resistance, and leakage. 
The chief obstacle always was human inertia, the most 
characteristic trait of mankind. If the success of any 
cause is contingent upon a general abandonment of the 
way of least resistance, that cause is already lost. An 
issue may have the passive favor of all the people and 
yet fail of fruitage through neglect. The old system 
tried to persuade the parents to do something; the 
school clinic only asks their assent. The school clinic 
attains the desired results and does it without friction. 

The opposition to free school clinics 

The opposition comes chiefly from practising physi- 
cians, some of whom look with apprehension upon 
every social movement which seems to point toward 
an ultimate socialization of their profession. The issue, 
however, becomes clear if we only remember that dis- 
ease is to be conceived as an evil to be eradicated, not 
as a resource to be conserved for the benefit of any 
profession. Partly by his own fault, and partly for 
social and economic reasons, the family doctor has 
failed to keep the people well. The family doctor insti- 
tution need not be abolished, but it must be supple- 
mented. What it has not done at all, or what it has 
done only with huge waste of effort, presents a legiti- 



THE SCHOOL MEDICAL CLINIC 119 

mate field for organized social endeavors. There is no 
likelihood that any considerable portion of physicians 
will oppose the general introduction of the school 
clinic, though organizations like the League for Med- 
ical Freedom may be expected to do so most vigor- 
ously. 

A committee of physicians commissioned by the 
local medical association to inquire into the bearing of 
the Bradford clinic upon private medical practice 
reported as follows: "Your committee consider that 
the school clinic as carried on at Bradford has not 
hitherto proved detrimental to the interests of practi- 
tioners of that district." ! What the school clinic ac- 
complishes is pure gain. 

To protect the health of children is a social obligation 

It is hardly necessary, interesting as it would be, to 
speculate upon the final outcome of the school clinic. 
Whether it will lead to the complete socialization of 
medicine and dentistry, just as education has been 
socialized, is a question it is impossible to answer. It is 
certain, however, that social regulation and control 
over matters pertaining to the health of children will 
be extended in the future rather than limited. Intrin- 
sically there is nothing more radical in the principle of 
free medical and dental treatment than in the Ameri- 
can scheme of public education and free textbooks. 
From the beginning the cry about weakening parental 

1 Quoted by Dr. Lewis Williams in his article on " School Clinics, " 
in School Hygiene for March, 1911. 



120 HEALTH WORK IN THE SCHOOLS 

responsibility has been raised against both. Gradually 
we are learning that it is less a question of parental 
responsibility than of children's rights. Private enter- 
prise has done too little for the health of our children to 
justify any claim to a monopoly of the business. It 
matters little what social procedure we adopt to insure 
that our children grow as nearly as may be into their 
full heritage of health and strength, as long as the end 
is accomplished. Least of all need we prematurely be 
frightened by the specter of socialism. To protect the 
bodies of children from defective development is not a 
question of socialism, but of humanity and of common 
sense. 

The school clinic is effective from the mere fact that 
it is an integral part of the educational machinery. It 
works in the closest relations with teachers, attendance 
officers, and nurses. The presumption is all in favor of 
the child. His case will be watched from day to day. 
The more it comes under the observation of the school 
physician, the greater is the probability that needed 
modifications of the curriculum will be made. In the 
words of Dr. Lewis Williams, "inasmuch as those very 
diseases which chiefly affect school children and play 
such havoc with school efficiency and school attend- 
ance are the very ones most neglected by parents in 
spite of medical inspection, the school clinic plainly 
becomes the only method of dealing with the diffi- 
culty." As forcibly stated by Hogarth, "to secure an 
improved physical condition for the next generation, to 
obtain a higher standard both of school attendance 



THE SCHOOL MEDICAL CLINIC 121 

and of education, to give a fair chance to thousands 
who are now hopelessly handicapped before the race is 
well begun, are aims which cannot be lightly set aside." 

Summary 

We may summarize the benefits of the school clinic 
as follows : — 

(1) It gives opportunity for a more thorough exam- 
ination of serious or puzzling cases than is possible in 
the ordinary routine of medical inspection. This bene- 
fit is derived from all school clinics and has no neces- 
sary connection with any scheme of free treatment. 

(2) It is the function of the school clinic to render 
the final decision in regard to segregations in open-air 
schools, special classes for the deaf and dumb, or 
schools for mentally defective children. 

(3) The bacteriological department of the school 
clinic regulates authoritatively and conveniently 
exclusions for contagious disease, and readmissions 
upon recovery. A certificate of freedom from contag- 
ion issued by the practising physician is often worth- 
less. The latter may have neither the bacteriological 
training nor the laboratory equipment to enable him 
to make scientific determinations of the presence or 
absence of pathogenic bacteria. Hogarth found that 
out of 240 certificates, issued by Bradford physicians, 
of freedom from scabies (itch), 234 were incorrect. 

(4) The school clinic alone is in position to maintain 
the close relations with the school and with the indi- 
vidual pupils which will insure the constant attention 



122 HEALTH WORK IN THE SCHOOLS 

necessary to the successful treatment of chronic de- 
fects. This is especially true of discharging ears, mal- 
nutrition, tuberculosis, etc. 

(5) In all lines of defectiveness the English type of 
school clinic brings results which it has not been pos- 
sible to secure by any other means. Through its work, 
eye defects are corrected, discharging ears are cured, 
adenoids are removed, teeth are repaired, verminous 
conditions are eradicated. The logical issue of diagno- 
sis is adequate and skillful treatment. This is what the 
school clinic insures. 

(6) The introduction of systematic and wholesale 
methods in preventive medicine, and the consequent 
saving of time, energy, and equipment, puts the whole 
matter upon a different economic basis. Adenoid oper- 
ations, eyeglasses, X-ray treatment of ringworm, and 
the like, are reduced to a small fraction of their former 
cost. Vaccinations by the school physician at the rate 
of twenty-five cents per child are just as effective as 
when performed by the practitioner for two dollars. 1 

(7) The school clinic should not be conducted as a 
semi-charitable institution. The practice of restricting 
treatment to such cases as have been investigated and 
recommended by local charity organizations is inde- 
fensible. To make a certificate of indigency the badge 
of admission is to brand those who accept its benefits 

1 Under the recent state law of compulsory vaccination at private 
expense Californians have been compelled to expend annually for 
vaccinations alone an amount of money large enough to support an 
efficient system of medical inspection for half the schools of the 
State. 



THE SCHOOL MEDICAL CLINIC 123 

with the stigma of pauperism. In protecting the lives 
and fostering the health of children it must be remem- 
bered that we are not conferring a charity, but per- 
forming a duty. 

(8) All the stock arguments against the operation of 
school clinics prove on examination to be untenable. 
To oppose the principle on which the institution rests 
is to deny the right and duty of society to engage in 
organized effort to conserve the raw material of the 
coming State. 

(9) The school clinic affords to the school doctor 
much-needed relief from the monotony of routine 
inspection. The importance of this point cannot easily 
be overestimated. Experience proves that after the 
novelty has worn off the work of inspection, the physi- 
cian is almost sure to become restless and discontented. 
He feels that he is not making any professional growth, 
as, indeed, is too likely to be true, considering the limi- 
tations and restrictions of his duties. Permission to 
give treatment both broadens his professional outlook 
and satisfies a legitimate and natural desire to accom- 
plish objective results. 

(10) The school clinic should be enlarged to include 
a psychological branch, in addition to the medical and 
dental work. 

REFERENCES 

*1. Crowley, Dr. R. H.: The Hygiene of School Life. 1910, pp. 167- 

83. 
2. Elder, Dr. M.: "The Deptford School Clinic." School Hygiene, 

1911, pp. 580-88. 
*3. Terman, Lewis M.: "School Clinics, Dental and Medical." 

The Psychological Clinic, 1912, pp. 271-78. 



124 HEALTH WORK IN THE SCHOOLS 

4. Tribe, Dr. R.: "Results of Treatment at the Poplar School 

Clinic (London.") School Hygiene, May, 1911. 
*5. Williams, Dr. Lewis : " School Clinics. " In Kelynack's Medical 

Inspection of Schools and Scholars, 1910, chapter xin, pp. 218- 

31. 
6. Williams, Dr. Lewis: "School Clinics." School Hygiene, March, 

1911. 



CHAPTER VIII 



SCHOOL DENTISTRY 

Historical 

School dentistry had its beginning in Strassburg, 
Germany, in 1902. The undertaking was due entirely 
to the enthusiastic efforts of Dr. Ernst Jessen, whose 
name therefore deserves an honored place in the his- 
tory of school hygiene. The Strassburg clinic is sup- 
ported at public expense, and is open without charge 
to the school children of the city, rich and poor. Al- 
though attendance upon the clinic is entirely volun- 
tary, the patronage has been very gratifying, as the 
following table will show. 

TABLE III 





No. treated 


No. available 
for treatment 


Total cost. 


1st year 

2d " 

3d " 

4th " 


2666 
4967 
6828 
7491 


17,119 
17,054 
18,073 
18,607 


$1355.00 
1685.00 
2135.00 
2250.00 



At first, more than half of those who offered them- 
selves for treatment were impelled by toothache, but 
the number coming for other purposes rapidly in- 
creased. A pupil seldom refuses to attend, when urged 
by the teacher. 

Results were evident from the beginning. After the 
repair of their teeth many children improved in health, 



126 HEALTH WORK IN THE SCHOOLS 

absence from school noticeably decreased, and in 
some cases discipline became easier. In Strassburg the 
clinic has the loyal support of the teachers, medical in- 
spectors, and a large majority of the parents. One of its 
most valuable results is the influence it exerts as a con- 
stant object lesson in hygiene to both pupil and parent. 

Before long the school authorities at Strassburg were 
overwhelmed with inquiries from every part of the 
world. By 1907, thirty-three cities and towns in Ger- 
many had instituted school dental clinics, and by 1909 
the number was about fifty. They are now quite gen- 
eral in the larger cities, and traveling clinics for rural 
schools are coming to be popular. 

In the smaller cities there are usually two or three 
school dentists, working on part-time. Wiesbaden, 
with 8000 school children, has six. Other cities, taking 
Strassburg for their model, employ full-time dentists, 
and admit them to pension rights on the same footing 
as teachers. 

The cost for salaries, materials, and up-keep of clinics 
is sometimes met entirely by public taxation, and 
sometimes in part by private philanthropy; but in 
either case the treatment is free to the pupil. The per 
capita expense in Germany is ridiculously small. As 
shown by the above table, the cost in Strassburg is less 
than twenty-five cents a year for each child treated. 
Of forty-nine cities reporting in 1909, the cost per 
child was greater than this in only four. 1 

1 Other cities in Germany, such as Mannheim, Stuttgart, etc., 
prefer to send the child to a private dentist of his own choice and to 



SCHOOL DENTISTRY 127 

In England, school dentistry has had a rapid devel- 
opment, though the sentiment there is less favorable 
to the free treatment of children whose parents can 
afford to pay. The Cambridge Dental Institute for 
Children, one of the best known of England's school 
clinics, was organized in 1907 at private expense, and 
was taken over after two years by the Borough Coun- 
cil. Before the work began in 1908, the average num- 
ber of unfilled carious teeth per Cambridge child was 
1, 2, 3, and 4 for the ages 6, 7, 8, and 9 respectively. 
After three years the number had fallen to .3, .6, 1.5, 
and 1.6 for the same ages. In 1908, 24 per cent of the 
children accepted treatment; in 1909, 25 per cent; and 
in 1910, 39 per cent. By this time 72 per cent of the 
children had sound, or artificially sound, teeth; before 
the work began, only 33 per cent. Of those urged to 
take treatment the first year, and refusing, 40 per cent 
accepted treatment later. 1 The greatest problem in 
Cambridge has been to get parents to bring the chil- 
dren, even though the treatment is absolutely free. 
Experience in other English cities proves that even a 
nominal charge dooms the school dental clinic to failure. 
One point in the Cambridge plan deserves special 
mention; namely, the concentration of effort upon the 
younger children. When the funds available are inade- 
quate to the task of putting in order the teeth of all the 
children, the Cambridge plan insures the greatest good 

pay the expense of the dental work done, rather than to employ a 
school dentist. Of course it matters little who does the work so long 
as it is really done. 

1 See Wallis, School Dental Clinics. (Reference 6.) 



128 HEALTH WORK IN THE SCHOOLS 

to the greatest number. The average cost of keeping a 
child's teeth in repair throughout its school life, begin- 
ning with the first year, is probably less than the aver- 
age cost of one treatment for the older child whose 
teeth have been neglected, and the good accomplished 
is proportionately greater. When this is done with 
every entering class the total expense involved is not 
large, and the teeth may thereafter be easily kept in 
satisfactory condition with but slight annual repairs. 1 
In the United States, dental clinics have been estab- 
lished in New York, Chicago, Philadelphia, Cleveland, 
Los Angeles, and in nearly all of the other large cities. 
Many of the smaller cities are following the example. 
Boston is fortunate in the establishment of the For- 
syth Dental Infirmary, made possible by the generos- 
ity of John Hamilton and Thomas Forsyth. The insti- 
tution is housed in a magnificent building and is en- 
dowed with $1,000,000 for maintenance. The gift is 
entirely for the benefit of Boston children under the 
age of sixteen years. Practical instruction in mouth 
hygiene is given, a dental museum is supported, and a 
room is available for public lectures. The institution 
also supports a research fellowship for the investiga- 
tion of dental diseases. 

Dental clinics should be free 

For the most part, the school clinic in the United 
States is conducted for the benefit of indigent, or semi- 

1 The same plan is being followed in West Newton, Massachu- 
setts. 



SCHOOL DENTISTRY 129 

indigent, children. It is frankly a charitable institu- 
tion, belonging in the same category as orphanages, 
poorhouses, etc. It is also different in that much of the 
dental service is rendered gratuitously by local dental 
associations. In those cases where the dentist receives 
pay for his school work the expense is usually borne by 
charitable organizations, and not by the school. 

The objections urged against the public support of 
free dental clinics are the same as those urged against 
school feeding, and precisely the same as those urged a 
few generations ago against free public schools: namely, 
that the people would be pauperized, that parental 
responsibility would be lessened, and that the income 
of private practitioners would be jeopardized. Experi- 
ence proves that the first two objections are ground- 
less. Parental responsibility is created rather than 
destroyed, and pauperization is no more caused by 
free school dentistry than by free textbooks and tui- 
tion. It is not even probable that the income of private 
dentists would be sensibly affected. The universal 
care of children's teeth in the schools would soon make 
the dentist habit universal, so that in a few years all 
persons beyond school age would be patrons of the 
private dentist, instead of the present 10 or 15 per cent. 
Moreover, many of the wealthier classes who now pa- 
tronize private dentists for their children would con- 
tinue to do so, even if free school clinics were estab- 
lished. The larger part of the work which is done by 
the free dental clinic would otherwise not be done at 
all. The good it accomplishes is clear gain. 



130 HEALTH WORK IN THE SCHOOLS 

Anyway, it is the welfare of the child which is sought, 
not the aggrandizement of a profession. By the whole- 
sale methods used in the schools, the cost of dentistry 
is reduced to about one third of what it would amount 
to if done by private dentists. There is no reason why 
society should neglect the teeth of children in the inter- 
ests of private dentists, any more than it should yield 
up their bodies in the interest of the private manufac- 
turer who fattens on child labor. 

We seem, indeed, to be on the eve of a great dental 
crusade, — a crusade which promises to make the 
public-school dentist as familiar a personage as the 
superintendent himself, and fully as indispensable. 
There is no alternative to the German method. 

In order to expedite his work, the school dentist 
stands in need of an assistant, just as the school doctor 
must have his nurses. Laws need to be enacted legal- 
izing the profession of the school dental nurse. The 
dental nurse, on proper certification, by examination 
or otherwise, would be permitted to examine teeth in 
the schools, clean them, and apply local treatment to 
allay pain. A large share of the school dentist's time 
would thus be saved. 

Preventing dental decay 

At least 80 per cent of the children in our schools have 
seriously defective teeth. In the upper grades, to be sure, 
many of these dental disabilities have been repaired. 
But a repaired tooth, after all, is only a makeshift. It is 
always in danger of a functional or organic breakdown. 




69 a 




Orthodontia restores the jaw to normal 




Teeth like these can be made straight. 
CROOKED TEETH 



SCHOOL DENTISTRY 131 

Modern dentistry is preventive in nature, and 
teaches that teeth need not necessarily decay at all. 
With a few exceptions, such as those found in certain 
cases of general faulty development, or conditions re- 
sulting from acute diseases, teeth may be kept from 
decay by the simple device of keeping them clean. 

The toothbrush cannot be relied on for this purpose. 
Not over twenty children out of a hundred use a tooth- 
brush with needed regularity, and hardly any of these 
know how to use it correctly. Most of them brush with 
a crosswise stroke instead of with an up-and-down 
motion. Even when correctly used the brush does not 
insure that every part of the tooth surface, inner as 
well as outer, will be kept clean. The latest and best 
method of insuring complete cleanliness, and thus 
guarding against decay is as follows: — 

As soon as the child has cut his first set of teeth, an 
attempt is made to remove placque formation as rap- 
idly as it occurs. Placques are deposits in and under 
which acid-forming bacteria find lodgment. Decay of 
teeth is due primarily to those bacteria of the mouth 
which produce lactic acid. This decay takes place 
under the placques. Consequently prompt removal of 
this deposit insures the teeth against decay. To detect 
the placques, which are often invisible to the eye or 
even the touch, the teeth are swabbed with a "disclos- 
ing solution" made of the tincture of iodine and a little 
glycerine. After the teeth are washed with water, the 
solution leaves the placques stained brown, while the 
rest of the tooth remains white. The brown spots or 



132 HEALTH WOEK IN THE SCHOOLS 

placques are now rubbed with a moist silica prepara- 
tion, and dental ribbon which is treated with the same 
material is run between the teeth. 

This procedure repeated about twice a month keeps 
the teeth relatively free from placques. It is necessary, 
however, to visit the dentist at least every six months 
for a more thorough treatment than can be given by 
the parent at home. This method followed conscien- 
tiously will prevent decay, give the enamel a beautiful 
luster and save at least seventy-five per cent of the 
usual expense for dental repairs. 

At best, dental repair is a purely mechanical process 
which gives evidence to the world of previous dental 
neglect. In only a restricted sense is it a hygienic mea- 
sure. The method just described, combined with the 
proper care of the gums and surface of the tongue, as- 
sures a degree of oral cleanliness which defies the as- 
saults of the bacteria of the mouth. 

REFERENCES » 

1. Jessen, Dr. Ernst: Die Zahnpflege in der Schule vom Standpunkt 
des Aerztes. 1909, pp. 67. 

2. Jessen, Dr. Ernst: " Schulzahnpflege u. Schule." Proc. 2nd Inter. 
Cong. Sch. Hyg., 1907, pp. 495-502. 

3. Jessen, Dr. Ernst: "Kostenpunkt einer Stadtischen Schulzahn- 
klinik." Inter. Mag. Sch. Hyg., vol. iv, 1908, pp. 432-36. 

4. Jessen, Dr. Ernst : " Die Zahnarztliche Behandlung der Volkschul- 
kinder." Inter. Mag. Sch. Hyg., 1907, pp. 205-22. 

5. Schlegel, Dr.: "The Reading (Pa.) Free Dental Dispensary." 
Psych. Clinic, February, 1910. 

6. Wallis, C. E.: School Dental Clinics: Their Foundation and Man- 
agement. London, 1913. 

7. Wimmenauer, Dr.: "Schularzte u. Schulzahnhygiene. " Zt f. 
Schulges., 1911, pp. 882-93. 

1 On problems relating to the growth and care of children's teeth 
see Lewis M. Tennan's, The Hygiene of the School Child, chapter xi. 
Houghton Mifflin Co., 1914. 



CHAPTER IX 

TRANSMISSIBLE DISEASES 

The mortality in the United States from measles, 
scarlet fever, whooping-cough, and diphtheria amounts 
every year to more than twice the loss of life on the 
field of Gettysburg. On the basis of the knowledge 
which we now have regarding the causes of these dis- 
eases and the modes of their transmission, probably 
more than half of this loss should be looked upon as 
absolutely preventable. The annual needless mortal- 
ity from this cause, therefore, exceeds the slaughter in 
most of the bloodiest battles of the world's history. 
Thousands of other deaths result from complications 
following children's transmissible diseases. 

The school as a factor in the spread of contagious diseases 

For some of this loss the school is directly respon- 
sible, particularly in the case of measles and diphtheria. 
Statistics collected from many parts of the world have 
established this beyond doubt. When society forcibly 
brings children together in the public school it is mor- 
ally responsible for the sickness and deaths which 
result from such compulsory contact. 

Thus Korosi found that for a large number of Ger- 
man cities, taken together, the average number of 
cases of measles per month, over a period of eighteen 



134 



HEALTH WORK IN THE SCHOOLS 



years, was less than one sixth as great during vacation 
as for the school months. Dr. Schaefer found similar 
differences for Hamburg, though the vacation decrease 
for scarlet fever and diphtheria was much less marked 
than for measles. In Chicago, for the two years 1899 
and 1900, the average monthly frequency of both scar- 
let fever and diphtheria was more than twice as great 
during the school months as in vacation. 

The following curve shows the average monthly 
mortality from measles in the city of London for the 



Jan. Feb. Mar. Apr. May. Jun. Jul. Aug. Sep. Oct. N*ov. Dee. 


60 
55 
50 
45 
40 
35 
30 
25 
20 
15 
10 
5 



























































































































































































































































































































FIG. 3 

Weekly average of deaths from measles in London, England, summed up for 
ten years, 1900-1910. See influence of vacation. (Fairfield.) 



O 

o 

© 

8 

r-C 


















•«= 


•c 


— — ' 


As 




"**, 




^ 

^ 


1- 




35 

i 

s 


S 




s 





s 




a 






a 


. — 


8 


-A 


s 




a 
3 




o 
-t* 






136 HEALTH WORK IN THE SCHOOLS 

years 1900 to 1910, averaged together. Attention is 
called to the marked influence of even the short vaca- 
tion there given. 

Fig. 4 shows a similar influence of the school on the 
prevalence of diphtheria in Halle, Germany, for the 
years 1906 to 1912 taken together. 

The school as a means of controlling contagious 
diseases 

However, in spite of the dangers which the school 
involves for the spread of contagious diseases, it affords 
at the same time unexcelled opportunity for their con- 
trol and prevention. Everywhere the medical super- 
vision of schools has accomplished much in this way. 
In the year 1906-07 medical inspectors discovered the 
following cases of contagious diseases in the public 
schools of Massachusetts : — 

TABLE IV 

Diphtheria 238 

Scarlet fever 313 

Measles 637 

Whooping-cough 973 

Mumps 367 

Chickenpox 548 

Influenza 276 

Syphilis 36 

Tuberculosis 115 

Scabies (itch) 1054 

Pediculosis (head lice) 7691 

Impetigo 1568 

Conjunctivitis 779 

Ringworm 715 

Other skin diseases, mostly contagious 1170 



TRANSMISSIBLE DISEASES 137 

These cases were all discovered among children 
present at school, and their immediate exclusion must 
have prevented a vast number of infections otherwise 
inevitable. 

Since medical inspection was instituted in Boston, 
diphtheria in that city has decreased 65 per cent and 
scarlet fever 15 per cent, and both are now less com- 
mon in school months than during vacation. In other 
words, by vigilance the school department of hygiene 
can more than offset the increased danger of epidemics 
incident to school attendance. When we remember 
that 90 per cent of all deaths from these diseases occur 
before the age of 10 years, the importance of their 
prompt and efficient control through the school ma- 
chinery readily becomes apparent. 

Our ideas on the transmissible diseases of children 
are rapidly changing. Instead of waiting for these dis- 
eases to make their appearance, we now attempt to dis- 
cover those conditions which favor them, in order that 
we may remove the soil most favorable to their growth 
and dissemination. 

'Newer ideas about modes of infection 

Recent studies of the contagious diseases of child- 
hood have brought about a radical change in our view- 
point in regard to their modes of infection. In the past 
it was the custom of both school people and medical 
officers to concentrate their attention upon the various 
objects (fomites) which had been in rather close con- 
tact with the sick person, as the probable sources of 



138 HEALTH WORK IN THE SCHOOLS 

infection. Within the meaning of this term were in- 
cluded a great many articles, such as bedding, books, 
toys, clothing, furniture, letters, desks, pencils, money, 
etc. 

At present the best informed medical men are paying 
less attention to fomite infection, and more to infection 
through personal contact. In other words, attention is 
now being fixed on 'persons rather than things as the 
sources of infection. Modern bacteriological investiga- 
tions have pretty conclusively demonstrated that in the 
majority of instances diseases are spread directly from 
one individual to another, rather than through an 
intermediate object of some sort. With the old theory 
of fomite infection, a great amount of time, energy, 
and money was expended on methods of disinfection, 
all to very little purpose. To-day far more efficient 
results are obtained by discovering, isolating, and con- 
trolling the individual carrier of the disease. Trans- 
missible diseases are, of course, transmitted only by 
means of living, active, micro-organisms of some sort. 
We are fast learning that these living organisms, or 
germs, which are either plant or animal in nature, 
cannot ordinarily live long outside of their particu- 
lar host. For this reason we believe less to-day than 
formerly in dust infection, air infection, book infection, 
infection through clothing and the like. 

Danger of the common cup, common towel, etc. 

Contact infection is undoubtedly the commonest 
and by far the most certain mode of infection. But 



TRANSMISSIBLE DISEASES 139 

contact infection does not exclude infection by means 
of various objects which may carry fresh material from 
the infected individual. Thus, diphtheria germs may 
easily be carried from the mouth of a sick child to the 
mouth of a well one by means of a pencil, provided the 
pencil has very recently been in the mouth of the child 
ill with diphtheria. Similarly a handkerchief used in 
common by a well child and one sick with measles 
easily carries the infection to the well child. 

What is said in this connection is not to be construed 
as a vindication of the common drinking-cup, which is 
always dangerous. Davison, who made bacteriological 
examinations of a large number of public drinking-cups, 
found that nearly all harbored dangerous germs, and 
that 37.5 per cent bore the tubercule bacilli. Bensel's 
experiment of allowing diphtheria patients to drink 
once from a glass sterilized for the purpose demon- 
strated that germs of the disease were deposited in from 
25 to 40 per cent of the cases. Measles, scarlet fever, 
whooping-cough, tuberculosis, and syphilis are known 
to be transmitted frequently in this way. The common 
drinking-cup in public places has been legislated out of 
existence in more than a dozen States since Kansas set 
the example in 1909. By 1911, more than forty rail- 
roads in the United States had substituted individual 
cups. 1 

The common cup and the common towel will both 
have to go. The best substitute for the former is a 

1 Common drinking-cups on inter-state trains were prohibited by 
federal regulation in 1912. 



140 HEALTH WORK IN THE SCHOOLS 

rightly constructed drinking-fountain, of which several 
are on the market. Individual cups are usually not 
kept clean, and are too often "borrowed." The com- 
mon towel should be replaced by absorbent paper tow- 
els, which are used once and then discarded. 

It has been shown also that books are capable of 
transmitting diseases, though the likelihood of their 
doing so has probably been exaggerated. At any rate, 
guinea-pigs have been inoculated with tuberculosis and 
other diseases by preparations made from library 
books. The danger from this source is probably suffi- 
cient to justify city boards of health in making daily 
reports on contagious diseases to public libraries, and 
books known to have been recently used by infected 
persons should be disinfected by the moist, hot air 
method. This requires exposure of the books for about 
thirty-two hours in an atmosphere of 80° C. (176° F.) 
and 30 to 40 per cent humidity. The method is said not 
to be injurious to the most delicate book. 

The modes of transmission just mentioned are in 
reality to be classed with contact infections. What is 
meant, then, by contact infection is contact with the 
virile specific germ of the disease, either directly 
through the patient or indirectly by means of an object 
which carries fresh material from the patient. It is not 
denied that infection by air or by fomites does some- 
times occur, but the evidence to-day is all against these 
modes in the great majority of cases. 



TRANSMISSIBLE DISEASES 141 

Air not a common source of infection 

It is not unnatural that air should have been so long 
considered one of the chief vehicles of infection, for it 
has been relatively few years since the germ principle 
of disease was discovered. Chapin says, "Until this 
germ idea was well established as a fact, the infective 
material was supposed to emanate from the surface 
of the body and from moist soil and decomposing 
matter of all kinds. Contagious diseases were known 
to arise without any apparent connection with other 
cases, and what could be more natural than to assume 
that the invisible, imponderable materies morbi is mixed 
with and carried by air? " Even to-day one finds some 
educated, as well as many ignorant, individuals and 
some entire communities believing that stagnant pools 
of water breed typhoid, that "sewer gas" may give 
rise to diphtheria, that drafts of air may cause pneu- 
monia, that air from marshes gives rise to malaria, etc. 
These and many similar delusions persist, despite the 
fact that we now possess abundant evidence to the con- 
trary. While it is possible that air may at times carry 
the germs of some diseases, it is now acknowledged by 
those most entitled to an opinion that air does not 
often carry germs in a condition capable of producing 
infection. That diseases are often spread in street- 
cars, trains, churches, schools, theaters, and other 
crowded places is, of course, a matter of common 
knowledge and experience; but these instances are sat- 
isfactorily explained by the fact that a large number of 



142 HEALTH WORK IN THE SCHOOLS 

individuals are here associated in close personal con- 
tact. It is easy under such conditions for infection to 
spread from one individual to another by means of the 
fine spray produced by coughing, sneezing, laughing, 
and the like. 

Isolation of "carriers" versus school closing 

The practical abandonment of the old idea of fomite 
and air infection, except in rather rare and exceptional 
instances, has resulted in an entire change of procedure 
in respect to the control of contagious diseases in 
schools. The time-honored method of closing and dis- 
infecting a school during an epidemic of measles or 
diphtheria is based on the theory of fomite and air 
infection in the school. This habit, still in practice in 
most places, results in loss of school time and expense 
to the school department. Worse still, many infected 
pupils are allowed to play about the streets among well 
children, and thus constantly spread the infection. 
The modern practice, which gives far better results, is 
to isolate the sick children and those believed most 
likely to be capable of carrying infection, while the 
school is kept in operation. 

It is now well understood that individuals who are 
not themselves sick may often carry the germs of cer- 
tain diseases in their bodies. This is true of diphtheria, 
typhoid fever, meningitis, pneumonia, influenza, tuber- 
culosis, and probably of scarlet fever, measles, whoop- 
ing-cough, mumps, and some other diseases. Such 
persons as carry in their bodies the germs of a dis- 



TRANSMISSIBLE DISEASES 143 

ease without themselves being sick, are known as 
"carriers." 

Dr. Chapin has remarked that probably the most 
important discovery bearing on preventive medicine, 
since the demonstration of the bacterial origin of dis- 
ease, is that disease germs frequently invade the body 
without causing disease. Where the throats of school 
children have been examined by the culture method 
during an epidemic of diphtheria, from 10 to 40 per 
cent of apparently well pupils have often been dis- 
covered who were carrying diphtheria bacilli in their 
throats, and were quite capable of giving the disease to 
others. In an epidemic of diphtheria which occurred in 
Berkeley, California, in 1906, Dr. George F. Reinhardt 
found 25 per cent of the well pupils to be carriers. 
Prompt isolation of both the sick pupils and the car- 
riers resulted in the control of the epidemic. 

Of 4526 contact cases among wage-earners, exam- 
ined in Providence, Rhode Island, during a diphtheria 
epidemic, 14.4 per cent were found to have the diph- 
theria bacilli present in their throats. It was signifi- 
cant in this instance that women were infected much 
oftener than men; the explanation being that women 
are in more constant and intimate contact with sick 
children than men are. 

The subject of contact infection cannot be dismissed 
without reference to atypical cases of transmissible 
diseases. Formerly it was supposed that most if not 
all diseases exhibited definite, characteristic symp- 
toms, and that mild atypical cases either did not exist, 



144 HEALTH WORK IN THE SCHOOLS 

or occurred infrequently. Now we know that many 
such atypical cases occur, and that, because of the 
fact that they often pass unrecognized, these cases are 
frequent sources of epidemics. Many such atypical 
cases have been observed in diphtheria, influenza, scar- 
let fever, smallpox, and typhoid fever, and there is an 
evidence of such cases in most other infectious diseases. 

The problem to-day is as much one of discovering 
mild, atypical diseases and carriers of diseases as of 
locating the ordinary cases. With the recognition of 
all or most of these carriers and atypical cases the con- 
trol of epidemics becomes a relatively simple matter. 
As long as mild, unrecognizable cases and carriers are 
allowed to go about freely, no possible good can result 
from the closing of schools. With the recognition and 
isolation of these cases, the closing of a school (with 
few or no exceptions) is not only unnecessary but posi- 
tively undesirable and even harmful, for the unrecog- 
nized, mild, atypical cases and carriers may then freely 
spread disease among other children. 

In epidemics of infantile paralysis, epidemic menin- 
gitis, and possibly a few other diseases, it may occas- 
ionally still be necessary to resort to the closing of 
schools, but if this procedure is unaccompanied by 
isolation of the exposed as well as the sick it can result 
in little good. As regards smallpox the prompt vaccin- 
ation of all unvaccinated children during the earliest 
days of an epidemic offers so perfect a protection to the 
well that closure of schools becomes an entirely unnec- 
essary and even harmful procedure. 



TRANSMISSIBLE DISEASES 145 

Ages at which transmissible diseases most often occur 

It is most important for schools to make accurate 
collections of data in respect to transmissible diseases, 
and to exhibit this so far as possible in a graphic form 
by means of charts and the plotting of curves. By this 




FIG. 5 

Curve indicating average seasonal occurrence of all children's diseases in the 
Berkeley Schools for the years 1906-1910. Note that the curve reaches its 
height in March. 

method, information can be instantly grasped and the 
problem of control can be more easily solved. The 
value of this procedure will be evident from the follow- 
ing study, made in the schools of Berkeley, California. 1 
A simple but instructive curve plotted from the 
average monthly reports of all transmissible diseases 
in Berkeley from 190G to 1910 shows that the curve 

1 Hoag and Hall, "A Preliminary Report on Contagious Diseases 
in Schools." Bulletin, American Academy of Medicine, 1911. 



146 HEALTH WORK IN THE SCHOOLS 

reaches its maximum in March. This clearly indicates, 
then, that March is the sick month of the year in this 
community. This period is coincident with the worst 
weather, when windows at home and at school are kept 
closed and pupils are at the same time in close personal 
association with one another and thus offer abundant 
opportunity for direct infection by contact. 

Plotting a combined age-curve for chickenpox, diph- 
theria, mumps, measles, scarlet fever, whooping-cough, 
typhoid, and tuberculosis, it appeared that 42 per cent 
of the diseases occur between the ages of 5 and 10 
years, and only 16 per cent between the ages of 10 and 
15 years; 79 per cent occur between birth and 15 years; 
only 13 per cent after 20 years. In other words, 68 per 
cent of the diseases in question occur in children of 
school age. Another 21 per cent occur in children too 
young to attend school. 

Of the reported cases of measles, 28 per cent occur 
under 5 years; 48 per cent between 5 and 10 years; 13 
per cent between 10 and 15 years; or a total of 89 per 
cent under 15 years. 

With mumps, only 6 per cent of the cases oc- 
cur under 5 years; but 50 per cent occur between 
5 and 10 years, and 26 per cent between 10 and 15 
years. 

In chickenpox, 61 per cent occur between 5 and 10 
years, and 14 per cent under five years; while 18 per 
cent occur between 10 and 15 years, and only 7 per 
cent occur after 15 years. 

In scarlet fever, 40 per cent occur between 5 and 10 



TRANSMISSIBLE DISEASES 147 

years, 28 per cent between 10 and 15 years, and 15 per 
cent under 5 years. 

Diphtheria gives 23 per cent for children under 5 
years, 35 per cent from 5 to 10 years, and 18 per cent 
from 10 to 15 years, the cases rapidly diminishing from 
this age on. 

In whooping-cough we get a different sort of result, 
as 52 per cent occur under 5 years of age, 39 per cent 
between 5 and 10, and only 5 per cent after 15 years. 

Typhoid exhibits no claim as a children's disease, as 
only 11 per cent occur under 10 years of age, and only 3 
per cent are reported in children under 5 years. 

In respect to tuberculosis, very few cases were re- 
ported among children; but we must remember in this 
connection that many latent general cases as well as 
some glandular and bone cases often fail to be re- 
ported. 



CHAPTER X 

TRANSMISSIBLE DISEASES 

(Continued) 1 

The most frequent diseases of children of school 
age are: — 

1. Measles. 

2. Scarlet fever. 

3. Diphtheria. 

4. Whooping-cough. 

5. Mumps. 

6. Chickenpox. 

7. Smallpox. 

8. Tuberculosis. 

9. Hookworm disease. 

10. Infantile paralysis. 

11. Epidemic meningitis. 

12. Eye diseases. 

13. Skin diseases. 

These diseases will be discussed in the order named, 
and such symptoms and complications will be given as 
will be useful to the non-medical reader. 

Further details concerning the transmissible dis- 
eases of children may always be obtained in a useful 
form from the various state boards of health, as well as 
from the city boards of health of the larger places. 
Some of these the reader ought to procure on account 
of their practical descriptions and their readily applic- 

1 The writers acknowledge their debt, in the preparation of this 
section, to Dr. James Kerr's Transmissible Diseases. 



TRANSMISSIBLE DISEASES 149 

able methods to school needs. The following Boards of 
Health publish particularly important and interesting 
bulletins and reports : — 

California State Board of Health — Sacramento. 
Minnesota State Board of Health — St. Paul. 
Indiana State Board of Health — Indianapolis. 
North Carolina State Board of Health — Raleigh. 
Michigan State Board of Health — Jackson. 
New York State Board of Health — Albany. 

1. Measles 

Measles is the most infectious disease of childhood, 
as well as the commonest. Practically every child who 
is exposed takes it the first time of exposure. It is most 
common during the first five years of life, but is often 
contracted between five and fifteen years, and occas- 
ionally during adult life. It rather rarely occurs during 
the first six months of life, but occasionally infection 
takes place before birth when the mother is suffering 
with the disease. 

While measles is not ordinarily regarded by the pub- 
lic as a serious disease, yet it is safe to say that it has a 
general mortality of not less than 4 per cent. Under 
bad hygienic conditions this mortality is often higher 
and may reach 10 to 40 per cent, while under very 
favorable conditions the percentage may be very low. 
The highest death rate is reached in the first and second 
years of life. 

In Aberdeen, Scotland, the statistics for twenty 
years show that of children under 3 years contracting 
measles 1 in 12 died, while the average rate for children 



150 HEALTH WOEK IN THE SCHOOLS 

over 3 was 1 death in 120 cases. The mortality was 
highest in the second year, 1 in 9. The importance of 
postponing the disease is, therefore, obvious. An epi- 
demic of measles in the kindergarten or lower grades 
should always be regarded with apprehension. The 
mortality from measles is always higher in cases in 
which other diseases exist, such as tuberculosis, 
syphilis, general malnutrition, etc. 

Complications. The mortality and serious morbidity 
of measles are not usually due to the toxins of the dis- 
ease itself, but to complications accompanying the dis- 
ease. The most important complications are those 
which affect the respiratory organs, such as bronchitis, 
broncho-pneumonia, and tuberculosis. Other less seri- 
ous complications are those of the eyes, ears, nose, and 
throat. 

After effects. The most serious after-effect of measles 
is tuberculosis. This occurs in a considerable number 
of cases, and for this reason the child should always 
receive the best possible hygienic care after recovery 
from the acute stages. 

Symptoms. Those who are intimately concerned 
with children ought to be familiar with the com- 
mon symptoms of children's diseases. The following 
are the usual and most evident indications of 
measles: — 

1. Catarrh of eyes, nose, throat. The child seems to have 
a cold. 

2. General lassitude. 

3. Fever. 

4. Eruption. 



TRANSMISSIBLE DISEASES 151 

The child usually begins to sneeze and blow his nose; 
his eyes soon become red and watery; often there is 
considerable cough; sometimes there is a chill; bluish- 
white spots surrounded by a red area are usually seen 
on the mucous membrane of the mouth, opposite the 
double teeth. These spots make their appearance be- 
fore the rash comes out. The rash usually shows about 
the fourth day of the disease, and begins on the face, 
neck, and head most frequently, and soon extends to 
the trunk, arms, and legs. The eruption begins as pa- 
pules, or small reddish spots, occurring in groups which 
have tendency to form irregular crescents. The papules 
do not form vesicles (small blisters), or pustules. 

Prevention. The great infectivity of measles, and the 
fact that it is most infectious before it can be easily 
recognized, make its prevention a matter of extreme 
difficulty. While compulsory notification cannot have 
the results which have been obtained with other infec- 
tious fevers, with our modern methods of medical 
inspection in schools much good ought to be accom- 
plished. 

Closure of schools has been found a very unsatisfac- 
tory method, and is productive of an enormous waste 
of school time. To secure a really efficient method of 
protection it will be necessary for the medical officers 
of schools to acquire an accurate knowledge of the 
health history of the school children. This may be ac- 
complished by keeping a list of all the diseases which 
the children have had. Provision should be made for 
this on the child's "Physical Record Card." 



152 HEALTH WORK IN THE SCHOOLS 

If during an outbreak of measles it is discovered that 
certain children have already had the disease, they 
need not be excluded from school. When a case of 
measles occurs in a class, all children who have not had 
the disease should be at once excluded. 

Rules on this point have been formulated for the 
London County Council, by Dr. Thomas, as follows: — 

(a) A child attending other than an infant school, who has 
already had measles, need not be excluded. 

(6) A child attending other than an infant school, who has 
not had measles, must be excluded until the Monday follow- 
ing the expiration of fourteen days from the occurrence of the 
first case. 

(c) A child attending an infant school, whether or not it 
has measles, is excluded for the same period. 

Disinfection. Disinfection of rooms at school or at 
home, as ordinarily carried out, probably has little or 
no effect, and is consequently a loss of time, energy, 
and money. Ordinary airing and cleaning will accom- 
plish all that is necessary, especially if the rooms are 
exposed to bright sunlight. Bedclothing and personal 
clothing should be thoroughly washed and aired. 

Willful exposure. Children should be protected as 
long as possible against infection with measles. It 
must not be forgotten that in any case, whether young 
or old, complications, such as tuberculosis, pneumonia, 
meningitis, ear disease, and eye troubles, may occur. 
The individual who willfully exposes a child to measles 
(a procedure which is far from infrequent) is guilty 
of criminal ignorance. 



TRANSMISSIBLE DISEASES 153 

2. Scarlet Fever 

Scarlet fever is one of the most serious of the diseases 
which affect children, and its after effects are particu- 
larly to be dreaded. It occurs at all seasons, but in epi- 
demic form is most likely to occur during the fall and 
winter months. 

Very little is known concerning the relation of tem- 
perature and climate to this disease, but like other 
eruptive diseases of childhood it is usually less severe 
in warm than in cold climates. 

Age occurrence. Scarlet fever is most common in 
children between 5 and 10 years of age, and more cases 
occur at the age of 6 years than at any other. Under 1 
year and over 15 years of age relatively few cases of 
scarlet fever are observed. The disease occasionally 
manifests itself in adult life, but out of 167,840 cases 
recorded by Ford Carger there were only 77 in indi- 
viduals past 50 years of age. There exists a great differ- 
ence in the degree of susceptibility of individuals 
toward this disease, some being practically immune, 
while others exhibit a high degree of predisposition to 
infection with it. 

Modes of infection. As with most other diseases, we 
now know that scarlet fever is most often spread by 
direct contact. Although the specific organism causing 
the disease has not yet been positively identified, it is 
probably present in the secretions of the nose and 
throat. There is reason to believe that the organism, 
whatever it is, may under some conditions be spread by 



154 HEALTH WOKK IN THE SCHOOLS 

carriers. Epidemics sometimes occur through infected 
milk supplies. Air infection plays little or no part in 
spreading this disease, and there is no evidence that 
water ever carries it. 

In respect to fomites, Kerr remarks that these may 
play considerable part in the dissemination of infec- 
tion. He further states that the clothes of a patient are 
highly infectious, and may remain so for a long period. 
It is difficult, he says, to accept without some reserve 
the tragic stories, so frequently related, of infection 
clinging to clothes or toys for over twenty years and 
then breaking out when the articles are disturbed. 
There can be little doubt, however, that clothing, 
books, letters, toys, and bedding can retain the virus 
alive for months, especially if they are excluded from 
light and air. 1 

Chapin, however, is disinclined to place much reli- 
ance in the various alleged cases of f omite infection in 
any of the transmissible diseases, and says that the 
amount of disease caused in this way is relatively very 
small. We have no need for such a theory and a much 
more satisfactory explanation is at hand. 2 

This explanation Chapin finds in the existence of 
healthy carriers and atypical cases. He also points out 
that if infection from fomites really occurred as often 
as has been supposed, transmissible diseases would be 
much more prevalent than they are. There is no good 
epidemiological evidence that diseases are spread by 

1 Kerr, James, Infectious Diseases. 

2 Chapin, C. V., Sources and Modes of Infection. 



TRANSMISSIBLE DISEASES 155 

fomites except in cases due to spore-forming bacteria. 
In schools, scarlet fever is not spread as readily as mea- 
sles or diphtheria. 

Duration of infectiousness. The patient is capable of 
transmitting the disease from the time his symptoms 
are first noted and until the catarrhal stage has disap- 
peared. As long as there is any inflammation in the 
nose or throat, or any discharge from the ears, the 
individual is infectious. It is also probable that infec- 
tion spreads from suppurating glands in the neck. It 
has always been supposed that the desquamating 
(peeling) skin was highly infectious, but to-day this is 
regarded less seriously than formerly, although the 
possibility of infection from this source cannot yet be 
entirely ignored. 

On an average, a child will be a possible source of 
infection for about six weeks, but each individual case 
must be judged by the disappearance of the catarrhal 
symptoms of the nose and throat, the ear discharge, 
the discharge from the lymphatic glands, and last, and 
probably of least importance, the disappearance of 
peeling. After exposure, a susceptible individual should 
be isolated for about ten days, as a matter of precau- 
tion. 

Period of Incubation. The symptoms of scarlet fever 
develop rapidly, the period of incubation in the major- 
ity of cases not exceeding seven days. More often it is 
not more than four days, and it is probable that most 
cases do not require over two or three days before they 
exhibit symptoms of the disease. 



156 HEALTH WORK IN THE SCHOOLS 

Early symptoms. For the guidance of the non-medi- 
cal reader the following early symptoms of scarlet 
fever are given: — 



A. General 


B. Specific 


Fever. 


Quick change from good health to 


Sore throat. 


sickness. 


Headache. 


Abrupt rise of temperature. 


Vomiting. 


Rapid pulse out of proportion to 


Chilliness. 


fever. 


Malaise. 


Sore throat. 



Of these symptoms the first four are the most signifi- 
cant in children. Vomiting and sore throat are almost 
invariably present. The rash usually appears in about 
twenty-four hours from the time of the appearance of 
the first symptoms. It usually appears first in the neck 
and chest, gradually spreading downward to the arms, 
trunk, and legs. The rash consists of minute points 
on a surface somewhat less red. The points are very 
closely set together, are no larger than half a pinhead, 
and are not much raised, at least not sufficiently to be 
felt by the finger. The appearance of the tongue is 
often somewhat characteristic. At first it is heavily 
coated and white. Later it has a "white strawberry" 
appearance. This is succeeded by a "red strawberry" 
stage. 

Mortality. Scarlet fever has not a very high mor- 
tality. In England it is said to be from 2 to 5 per cent. 
This varies greatly, however, with the age of the pa- 
tient. For children under 1 year of age it may reach as 
high as 21 per cent, and for children between 1 and 2 



TRANSMISSIBLE DISEASES 157 

years of age, 16 per cent. In general, the younger the 
patient, the higher the death rate. From 10 to 15 years 
of age is said to be the period of fewest fatalities. 

Complications. Scarlet fever has associated with it 
more serious complications than has any other of the 
eruptive diseases of childhood. Of these complications 
the following are the most important: — 

1. Nephritis (Bright's disease). 

2. Arthritis (articular rheumatism). 

3. Heart disease : — 
(a) Endocarditis. 
(6) Pericarditis. 

4. Adenitis (inflammation of the lymphatic glands). 

5. Otitis media (inflammation of the middle ear). 

6. Rhinitis (inflammation of the nasal passages). 

7. Tonsillitis. 

8. Broncho-pneumonia. 

9. Meningitis. 
10. Diphtheria. 

Nephritis, or Bright's disease, is not rare in cases of 
scarlet fever, even in mild cases, and sometimes it per- 
sists as a permanent organic disease of the kidneys. It 
is not as yet clear whether this complication is caused 
by the toxin or by the germ of scarlet fever, but it is 
probable that both play an important part. 

After 10 years of age nephritis is rarely encountered 
as a complication. On the other hand, when Bright's 
disease occurs in children under ten, scarlet fever ought 
to be thought of as a possible explanation, as it may be 
present in a mild, unrecognized form. Kidney compli- 
cations probably occur in not less than 10 per cent of 
the cases. 



158 HEALTH WOKK IN THE SCHOOLS 

Arthritis, or rheumatism of the joints, is said to 
occur in about 4 per cent of all cases, and in more than 
half of all these it appears in children past 10 years of 
age. Muscular rheumatism also appears in some scarlet 
fever cases and is probably caused by the toxins of the 
disease. 

Heart complications are not very common, but when 
they do occur they are most often coincident with 
rheumatism. Of 22,096 cases of scarlet fever observed, 
endocarditis — inflammation of the lining of the heart 
— appeared in only 0.58 per cent of the entire number. 

The commonest complication of all in scarlet fever 
is otitis media, or inflammation of the middle ear. Usu- 
ally about 12 per cent of cases are observed to be thus 
affected. The germs setting up the inflammation may 
be carried either through the eustachian tube from the 
nose and throat, or by means of the blood. 

The discharge which takes place from one or both 
ears may be transient in character, or may last for 
months or years. This condition may, of course, pro- 
duce more or less permanent deafness, especially in 
cases which do not receive proper treatment. It seems 
very probable that discharging ears may be the cause 
of scarlet fever infections in many cases. Sometimes a 
mother will attribute a case of scarlet fever in the 
family to the fact that some clothing or toys which 
were not completely disinfected at the time of occur- 
rence of a previous case, perhaps years before, had 
been recently unpacked and handled. An investiga- 
tion in such cases often demonstrates the presence of a 



TRANSMISSIBLE DISEASES 159 

discharging ear in the previous case, which has per- 
sisted since the time of the scarlet fever attack. It is 
far more reasonable to attribute infection to such a 
source rather than to any organisms remaining active 
for a long period in clothing. 

Diphtheria, following scarlet fever or associated with 
it, is often observed. This may in part be explained by 
the fact that the child may have been a diphtheria car- 
rier and that the germs have become active during the 
attack of scarlet fever, or that the resistance has be- 
come reduced because of it. Until antitoxin was em- 
ployed, this complication was the cause of a fearful 
mortality, but with its early and general use the danger 
has been greatly reduced. 

3. Diphtheria 

Diphtheria is one of the few diseases for which a 
specific treatment has been discovered. The use of 
antitoxin has not only greatly reduced the mortality 
from the disease, but has also decreased the seriousness 
of sickness incident to it. The bacillus which causes 
diphtheria was discovered by Klebs in 1883, and much 
of the modern treatment of germ diseases dates back 
to this period. 

Age. Diphtheria occurs most frequently during the 
first ten years of life. Under 1 year of age it is not com- 
mon, but it is met more frequently during the period 
from 2 to 5 years than at any other time. After 12 
years of age it is relatively uncommon. 

Modes of infection. Direct contact explains satisfac- 



160 HEALTH WORK IN THE SCHOOLS 

torily the greatest number of cases, although indirect 
contact, from the common use of such articles as pen- 
cils, handkerchiefs, towels, common eating-utensils, 
and the like, may account for a good many cases. Some 
epidemics appear to have originated in infected milk 
supplies. 

Carriers are very common in diphtheria, and the con- 
trol of the sick cases and carriers is usually all that is 
necessary to stop an epidemic of this disease. Chapin 
thinks that perhaps 1 or 2 per cent of the population 
carry the germs of diphtheria constantly in the nose 
or throat. Among those that have been in close con- 
tact with diphtheria cases the percentage of carriers 
is usually pretty high; 10 to 15 per cent is not an un- 
usual proportion under such conditions. In schools 
where there have been epidemics of diphtheria it has 
not been uncommon to discover that from 25 to 50 per 
cent of the well children are carriers of the bacillus, and 
are therefore capable of spreading the disease. 

It often happens that atypical cases of diphtheria 
occur, cases which are so mild in character that they 
may even be overlooked by physicians. From mild 
cases of this type serious cases and even epidemics may 
result through the infection of susceptible individuals. 
Every case of definite sore throat ought to be regarded 
as a possible case of diphtheria, until proved not to be 
one. The only possible way to determine the facts is 
by use of the culture method; i.e., the throat must be 
swabbed and the bacteria grown on an artificial culture 
medium for twelve to twenty -four hours, and then 



TRANSMISSIBLE DISEASES 161 

examined bacteriologically. Every competent health 
officer now has facilities for such diphtheria examina- 
tions, and the public ought to make free use of the 
opportunities thus afforded. 

It should never be forgotten that diphtheria and 
scarlet fever are often associated. Therefore, in scarlet 
fever, cultures from the throat should be taken as a 
matter of precaution. 

The old idea that diphtheria may be spread by defec- 
tive drains, "sewer gas," stagnant water, "bad air," 
and the like needs only to be mentioned to be con- 
demned as a superstition. Fomites play no more im- 
portant part in spreading diphtheria than they do in 
most other transmissible diseases. For infection to be 
carried in this manner the infective material must be 
relatively fresh. The domestic cat sometimes suffers 
from diphtheria, and there is sufficient evidence to lead 
us to believe that this animal may infect human beings 
who come into direct contact with it. Diphtheritic 
patches and ulcers sometimes occur on the udders of 
cows, and a few milk epidemics have been traced to 
such sources. 

It is not possible to state just how long it takes the 
disease to develop in a suceptible person after exposure, 
but there is good reason to believe that it sometimes 
appears as soon as twenty-four hours. On the other 
hand, the germs may be carried in the nose or throat 
for days, weeks, or months, before any symptoms ap- 
pear, while in other instances, as we have already 
learned, a carrier may show no symptoms of sickness at 



162 HEALTH WOEK IN THE SCHOOLS 

all. Ordinarily about two or three days will be required 
for the disease to develop. 

Symptoms. The prominent and common symptoms 
of diphtheria are as follows : — 

Fever. 

Headache. 

Malaise. 

Chilliness. 

Lassitude. 

Rapid pulse. 

Loss of appetite. 

Sore throat. 

Patches of whitish membrane in the throat. 

Complications. Broncho-pneumonia may occur and 
is always a very serious complication. Inflammation 
of the middle ear (otitis media) is not rare, and some- 
times the discharge contains diphtheria germs. 

Paralysis of various parts is not uncommon, and is 
due to the toxins of the disease. Paralysis of the heart 
is the cause of many of the sudden deaths in attacks of 
diphtheria, or during early convalescence. In some 
cases the muscles of the eyes are affected; in others 
those of the legs, arms, throat, face, or the muscles of 
respiration. Sometimes the paralysis occurs in several 
parts of the body. 

Mortality. Before the use of antitoxin, the death rate 
from diphtheria was very high, often reaching 25 or 30 
per cent of the cases, while 25 to 40 per cent was not 
unknown. With the early use of antitoxin this terrible 
mortality has been reduced to from 3 to 14 per cent, 
depending upon the severity of the epidemic. If a 



TRANSMISSIBLE DISEASES 163 

diphtheria case is treated with antitoxin serum the first 
day, death very seldom occurs; but every day of delay 
adds to the risk. It should be understood that antitoxin 
also affords protection against diphtheria in the cases 
of exposed persons, and it is especially important to 
administer it in the case of those who carry the germs 
in the nose or throat. 

Control of an epidemic of diphtheria. A matter of 
prime importance in the control of diphtheria is to 
recognize the cases early, and isolate them. Next in 
importance is the discovery of carriers, and the isola- 
tion of these also. Last of all, no cases of either class 
should be allowed to mingle with other children (or 
adults) until examination proves that the germs of the 
disease have entirely disappeared. 

It is probably never necessary for a school to be 
closed if the precautions just described are carefully 
observed, though it is, of course, necessary to clean and 
disinfect the desk and personal belongings of the chil- 
dren who are known to have been infected. 

Conclusions from the investigation of an epidemic in a 
Berkeley (California) School 1 

The existence of an epidemic of diphtheria in one of 
the schools of Berkeley afforded an opportunity to 
make an exhaustive trial of the control of diphtheria 
by strictly laboratory methods. 

The local health authorities first became alarmed 

1 Abstracted from a Report by Archibald A. Ward and Margaret 
Henderson. 



164 HEALTH WORK IN THE SCHOOLS 

about diphtheria in Berkeley early in November. In 
October five cases were reported, four of them from 
the Lincoln School District. In the first half of 
November ten cases were reported, nine of them from 
the Lincoln School District and two of them resulting 
in death. Besides these reported cases, there were un- 
official rumors of many others. 

A great clamor arose among the inhabitants of the 
region, and those of other parts of Berkeley who heard 
of the epidemic, insisting on the closing of the school 
until the diphtheria should be over. But it was deemed 
wiser to keep the school open, excluding all children 
who showed diphtheria bacilli in their throats. If the 
school closed, all children would go out of the control 
and observation of the health officer. If it were open, 
they would remain segregated, new cases would be 
easily traced, and old cases more easily kept quaran- 
tined until free from infection. It was, therefore, de- 
cided to examine every child in the school, excluding 
all those showing diphtheria bacilli, and readmitting 
infected ones only after two negative cultures had 
been obtained from them at an interval of at least a 
week. 

The school was then closed for the three days neces- 
sary to examine the cultures, and when it was reop- 
ened, those children showing diphtheria bacilli were 
sent home, together with their sisters and brothers. 
No attempt was made to disinfect the school at any 
time during the epidemic. The principal undertook to 
see that the desks of the children found to be infected 



TRANSMISSIBLE DISEASES 1G5 

were washed in a 4 per cent formalin solution, and that 
their books and pencils were sent home with them. Be- 
yond this nothing was done in the way of disinfection 
at any time. 

About 475 children were examined, and 27, or about 
5 per cent, were found positive. There was no attempt 
to quarantine these children; they were merely ex- 
cluded from the school. 

The first examination did not stop the epidemic and 
it was decided that the second one must be made more 
stringent. Various changes were made, for this reason, 
in the technique. Cultures were taken from the throat, 
as before, but, in addition, cultures were also made 
from the nose, on the same tube of blood serum. 

In this second examination, 77 of the 550 children, 
or 14 per cent, were found to be harboring diphtheria 
bacilli. This meant the exclusion from school of a total 
of 125 children. 

Conclusions 

(1) The epidemic was due to three factors: (a) Exist- 
ence of mild cases of diphtheria which, because of the 
lack of bacteriological examination, had gone un- 
recognized as diphtheria; (b) the insufficient length of 
quarantine in clinical cases; (c) germ cases following 
exposure and never showing clinical symptoms (car- 
riers). 

(2) Attempts to isolate all infected children had no 
effect on the course of the epidemic, so long as throat 
cultures only were made. When both nose and throat 



166 HEALTH WORK IN THE SCHOOLS 

cultures were made and all the children showing posi- 
tive cultures were quarantined, the epidemic stopped. 

(3) It is extremely important, in times of danger 
from diphtheria, that every sore throat, no matter how 
far it may seem to be from diphtheria, be regarded as 
suspicious until a bacteriological examination has 
proved it to be otherwise. 

(4) It is such a frequent occurrence to have a posi- 
tive culture follow a negative one that at least two 
negatives should be demanded for release from quaran- 
tine. No case should be released on clinical signs alone. 

(5) It is possible to stop epidemic diphtheria in a 
public school by regulation of attendance by means of 
bacteriological findings. 

4. Whooping-cough 

Until recently the organism of whooping-cough was 
unknown. Now it is generally recognized as an influ- 
enza-like bacillus called the "Bordet Bacillus." Whoop- 
ing-cough is very largely a disease of infancy and early 
childhood. If a child can be protected against the dis- 
ease until he is five or six years old, his chances of tak- 
ing it are very greatly reduced. The greatest number of 
cases probably occur in the fourth year, but the disease 
is common in children under 1 year of age, and some- 
times occurs in babies less than 2 months old. After 10 
years of age, whooping-cough is relatively rare, but 
occasionally adults are affected, and, in rare cases, the 
aged. 

Mode of transmission. Whooping-cough is trans- 



TRANSMISSIBLE DISEASES 167 

mitted very largely, if not exclusively, by direct or 
indirect contact. The disease is extremely contagious, 
although not as much so as measles. The period of in- 
fectiousness extends from the earliest catarrhal symp- 
toms, which first appear as an ordinary cold, until the 
cough has ceased. One attack of whooping-cough prac- 
tically protects for life against reinfection. 

Not much is positively known about the period of 
development of whooping-cough, but this probably 
varies from one or two days to two weeks. If, after 
exposure, the disease has not appeared within fifteen 
days, there is little or no danger that it will appear at 
all. 

Symptoms. It is highly important to understand 
that whooping-cough usually begins much like an ordi- 
nary cold, with cough, and that it is often if not usually 
unrecognized for a number of days. Generally the 
cough becomes progressively more severe, and by the 
end of the first or second week the paroxysmal charac- 
ter of the cough makes the case a clear one. 

This paroxysm associated with the cough may occur 
a few or many times during the twenty-four hours. 
The child coughs violently in quick succession and is 
unable to get his breath; his face becomes very red or 
even purple, and he presents a rather alarming appear- 
ance. At last the breath is drawn in with a "whoop," 
which may or may not end the particular spasm. 
Vomiting usually occurs at the end of the "whoop," 
but sometimes precedes it. 

Duration. One of the many unfortunate features of 



168 HEALTH WORK IN THE SCHOOLS 

whooping-cough is its long duration. On the average 
this covers a period of five or six weeks. The "whoop " 
may persist for a much longer period than this, and 
sometimes it continues for several months, or even for 
a year. 

Complications. Whooping-cough should be regarded 
seriously for several reasons. First of all, it keeps the 
child out of school for several weeks or months; second, 
it causes a tremendous strain of the heart and lungs; 
third, it has many possible complications. Among 
these are: — 

Hemorrhages in the eyes, nose, bronchial tubes, and occa- 
sionally in other localities, including the ear, skin, and brain. 

Digestive disturbances. 

Hernia (rupture). 

Broncho-pneumonia. 

Nervous complications of various kinds, such as convul- 
sions, and, in rare cases, paralysis. 

Heart strain not infrequently occurs in severe cases. This 
may result in permanent injury, but more often it is of tem- 
porary character. 

Tuberculosis often follows long attacks of broncho-pneu- 
monia, and is much to be dreaded in such cases. 

Control. Whenever there is an epidemic of whooping- 
cough, every child with a suspicious cold and cough 
ought to be excluded from school and kept under ob- 
servation for about two weeks. Such a precaution will 
greatly reduce the number of cases in a school. Chil- 
dren who develop the disease should be isolated for a 
period of about six weeks, and it is unsafe to allow 
them to mingle with other children until the "whoop" 
has disappeared. A slight cough without the "whoop" 



TRANSMISSIBLE DISEASES 169 

may ordinarily be ignored, as this often persists long 
after all danger of infection has passed. A bacterio- 
logical examination for the presence of the specific 
germ of the disease will of course settle the question of 
the infectiousness of a case. 

All expectorations should be carefully destroyed by 
disinfectants, or by burning. Disinfection of articles 
which may carry infection ought to be practiced as a 
matter of precaution, although there is probably rela- 
tively little danger of infection from such sources. 

Children from families in which there is whooping- 
cough need not be excluded from school, if they them- 
selves have had the disease. If they have not, unless 
over 10 years of age, they should be excluded for at 
least two or three weeks. After this they may return, 
but should be carefully watched for symptoms. 

5. Mumps 

Mode of transmission. While the specific germ of 
mumps has not been discovered, there is no doubt as to 
the existence of such an organism. Some regard the dis- 
ease as a septicaemia, or general infection in the blood. 

Season has little to do with the occurrence of mumps, 
but age is a factor of much importance. The disease is 
not common in the very young, or in those past middle 
life. It most often occurs between the ages of 5 and 15 
years. In the Berkeley, California, investigation (Hoag 
and Hall), 50 per cent of the cases occurred between 5 
and 10 years, and 26 per cent between 10 and 15 years. 

We are rapidly learning that most infectious diseases 



170 HEALTH WORK IN THE SCHOOLS 

are spread directly or indirectly from the secretions of 
the nose and throat, and in this respect mumps appears 
to offer no exception. 

Mumps may be called a school disease. Epidemics in 
high schools and colleges are not uncommon, and they 
often appear also in barracks. The disease is not very 
contagious, the susceptibility of children to it being 
much less than in the case of other transmissible dis- 
eases of childhood. 

It is contagious from the time of the appearance of 
the earliest symptoms, and probably usually remains 
so for several days after the disappearance of the 
swelling. The period of incubation varies considerably, 
but is usually from three days to three weeks, with an 
average period of about twenty days after exposure. 

Symptoms. Often the swelling of the parotid glands 
(at the angle of the jaw) is the first symptom. In some 
severe cases there may be headache, pains in the back 
and legs, and vomiting and fever for about one day 
before the appearance of the glandular swelling. Pain 
often precedes the swelling of the parotid glands, and 
the glands may swell on one or both sides of the neck. 
Usually the swelling reaches its limit in two or three 
days, and then remains stationary for a few days, when 
it slowly decreases. Ordinarily the swelling completely 
subsides in a week or ten days from the beginning of 
the process. Other glands of the neck are occasionally 
affected, but in any event the course of the disease is 
nearly always mild and uneventful. 

As a complication, swelling of the sexual glands (tes- 



TRANSMISSIBLE DISEASES 171 

tides or ovaries) occasionally occurs. This is rarely 
observed before puberty, but after this period it may 
appear in either sex. Other complications are not often 
met with, and need not be mentioned here. 

Control. In the majority of cases the symptoms will 
not appear until at least a week after exposure. Con- 
sequently an exposed child who has not had the disease 
need not be isolated during the first week. After that 
it is well to practice isolation for a period of about two 
weeks. Second attacks are possible, but are so infre- 
quent as to be negligible. Disinfection, except of desks 
and the personal belongings of the child, need not be 
practiced. 

6. Chickenpox 

While chickenpox is usually mild and harmless, yet 
this is not always the case, and in exceptional instances 
some severe complications may arise. A point of par- 
ticular importance is that it is frequently confused 
with smallpox, every physician having seen cases of 
beginning smallpox diagnosed "chickenpox." At one 
time it was supposed that chickenpox was a mild form 
of smallpox, but since about 1870 there has been no 
controversy in regard to this point. 

Varicella, or chickenpox, originates through infec- 
tion only, but just how this comes about we are still in 
doubt. Most authorities doubt if this disease is ever 
carried by a third person or by fomites. It is also 
doubtful if air transmission plays any part in the spread 
of the disease. 



172 HEALTH WORK IN THE SCHOOLS 

The contagiousness begins as soon as the eruption 
appears, and probably continues until all crusts have 
fallen from the skin. 

It is rare that an individual ever has more than one 
attack, but this does occur occasionally. Chickenpox 
is a universal disease, and is rarely altogether absent 
from large centers of population. It occurs most often 
in the epidemic form, soon after the opening of schools. 

Chickenpox is so rare in adults that every such case 
ought to be very carefully distinguished from smallpox. 

The early symptoms are: — 

Fever. 

Loss of appetite. 

Restlessness. 

Malaise. 

Vomiting. 

Nosebleed. 

The eruption usually comes out in from one to four 
days after the appearance of the first symptoms, but 
sometimes the noticeable symptoms and the eruption 
seem to occur simultaneously. The eruption begins as 
small papules (little red spots), which soon change into 
vesicles (little blisters). These vesicles soon dry and 
in a day or so leave scabs, which usually fall off after 
two or three days. All stages of the eruption may be 
observed on the body at the same time. 

Complications. Complications are very rare, but do 
occur in a number of different forms, as follows: — 

Nephritis (kidney disease). 
Arthritis (rheumatism). 
Paralysis. 



TRANSMISSIBLE DISEASES 173 

Chorea. 
Infections. 
Gangrene of skin. 

Control. The child should be excluded from school 
from the time of the earliest symptoms until the scabs 
have disappeared. 

7. Smallpox 

An exact knowledge of smallpox is important, be- 
cause in mild cases it is easily confused with chicken- 
pox. It not infrequently happens that a case of small- 
pox is so mild that it does not even present the slight 
symptoms common to chickenpox. 

Onset of the disease. In smallpox there is always some 
fever for a period of about three days before any other 
marked symptoms appear. With fever there is associ- 
ated headache, general malaise, and often such symp- 
toms as occur with a slight influenza. After the third 
day from the beginning of the symptoms the eruption 
comes out, and the person thereafter feels better for a 
time, or indeed does not again feel sick at all. "There 
is no other eruptive disease in which such experience as 
this can be noted; it is peculiar to this one." 

The distribution of the eruption. On the third day, 
with subsidence of the fever, the eruption appears. It 
appears first on the face; later on the back of the hands 
and wrists. 

In chickenpox the definite onset which character- 
izes smallpox is lacking. The early symptoms in 
chickenpox are usually insignificant, and the fever 
does not subside with the appearance of the eruption. 



174 HEALTH WORK IN THE SCHOOLS 

The red spots (papules) are not so hard in chickenpox 
as in smallpox, and they quickly form blisters (vesicles). 
The eruption is most abundant on the trunk and es- 
pecially on the upper part of the back, while the face is 
fairly free. 

Vaccination affords almost perfect protection against 
smallpox. The literature on this subject is so exhaus- 
tive that merely to mention the titles of the most im- 
portant articles is out of the question. For a concise 
and conclusive argument, however, in favor of vaccina- 
tion, the reader may be referred to Vaccination: What 
it is; What it does; What its Claims are on the People, 
issued by the New York State Department of Health. 

Every individual ought to be protected against small- 
pox by vaccination, but in any event vaccination must 
be practiced at the time of any appearance of this dis- 
ease among school children. 



CHAPTER XI 

TRANSMISSIBLE DISEASES 

(Concluded) 

8. Tuberculosis 

The subject of tuberculosis has been fully discussed 
in the volume of this series called The Hygiene of the 
School Child, and it is, therefore, unnecessary to enter 
into any extended details at this point. 1 

"Open" and "latent" tuberculosis. "Open" tuber- 
culosis, by which is meant tuberculosis in the trans- 
missible form, such as is found in unhealed tuberculous 
conditions of the lungs, is rarely met by school health 
officers in their routine work. Evidence of former bone 
tuberculosis is seen not infrequently in the form of de- 
formed spines (kyphosis) or a shortened leg, usually 
caused by hip-joint disease. Scars in the neck most 
often represent former tuberculous lymph-glands which 
have either ruptured spontaneously or have been 
lanced. Occasionally one observes discharging lymph- 
glands of tuberculous nature in the neck or the groin, 
and, less often, abscesses in the back. Also, in relatively 
rare instances, cases of active pulmonary tuberculosis 
are found. In the main, however, tuberculosis in school 
children is of the latent type, discoverable chiefly by 
use of the Von Pirquet test. 

1 See also chapter xu of the present volume, "Open- Air Schools." 



176 HEALTH WORK IN THE SCHOOLS 

That a very large number of children are afflicted 
with latent tuberculosis there is no possible doubt, and 
modern investigations point to the fact that most 
tuberculosis is acquired in childhood, even though it 
may not become evident for many years. It is the con- 
viction of one of the writers, who has personally exam- 
ined more than 100,000 school children, that most of 
the type which we call "malnourished" are in reality 
cases of latent tuberculosis. This opinion is shared by 
some others who have had wide experience in dealing 
with children. For the reason just stated, if for no 
other, cases of malnutrition should receive prompt and 
careful attention. 

Not nearly so many instances of malnutrition as we 
imagine are really caused by insufficient food. If this 
were the fact fewer such cases would be observed 
among the children of the well-to-do. Malnourished 
children always greatly improve by treatment in open- 
air schools where feeding, fresh air, and rest are skill- 
fully combined. An attempt should always be made to 
discover the nature of home conditions in these cases, 
for in some instances tuberculosis will be found present 
in one or more members of the family. 

One ought to suspect the possibility of tuberculosis in 
children who show some or all of the following signs: — 

Delicate constitution. 

Tendency to tire out easily. 

Pallor. 

Flushed face at certain periods. 

Capricious appetite. 

Enlarged cervical (neck) glands. 



TRANSMISSIBLE DISEASES 177 

Adenoids. 
Diseased tonsils. 

No delicate child should be neglected. The time to 
control tuberculosis is at the beginning, when the dis- 
ease may be indicated only by some such general signs 
as those just mentioned. 

The teacher's health must receive attention, partic- 
ularly in respect to tuberculosis. One tuberculous 
teacher of careless or uncleanly habits has opportunity 
to infect the 40 or 50 children in her classroom, and 
through them to send infection into as many homes, ex- 
posing in the end 200 or 300 individuals to the chance 
of infection. As stated by Dr. Langley Porter, "when 
we consider the contact of child with child, a contact 
maintained for hours daily, often in an ill-ventilated 
room, we realize that the danger here is very real. A 
proper school inspection will mean the elimination of 
the actually tuberculous pupil and teacher from con- 
tact with healthy pupils and instructors." 

Prevention. To summarize the means of preventing 
tuberculosis in school children we may mention the 
following essential points: — 

(1) Elimination of the tuberculous teacher. 

(2) Segregation of the tuberculous school child. 

(3) Building up the health of all anaemic, nervous, and 
weak school children. 

(4) Short school day for young children. 

(5) Well-ventilated schoolrooms. 

(6) Sanitary schoolrooms. 

(7) Open-air schools. 

(8) Low temperature schools (temperature not to exceed 
60° to 68° F.). 



178 HEALTH WORK IN THE SCHOOLS 

(9) Common-sense physical training, out of doors. 

(10) More careful health observation on the part of teachers. 

(11) Systematic health inspection of schools. 

(12) Home visits by nurses. 

(13) Knowledge of the nature of the food which school chil- 
dren receive. 

(14) Common-sense, applicable, hygiene instruction. 

9. Hookworm Disease 

Hookworm is not often seen in the school children of 
this country, except in the Southern States. The dis- 
ease is also common among the Japanese, Hindus, 
Porto Ricans, and in some of the countries of southern 
Europe. In the tropics the disease is said to be "the 
greatest enemy of the human race." In the United 
States hookworm has been found common from Vir- 
ginia to Florida and Texas. In a few other States it 
has been observed rather infrequently. It is estimated 
that at least 2,000,000 people of our Southern States 
are infected. 

Mode of transmission. The commonest cause of in- 
fection among school children is the habit of going 
barefooted. The disease commonly gains entrance in 
one of two ways — first and most commonly, through 
the skin; second, and less frequently, through the 
mouth. Dock * states that the reproductive stage is 
reached only in the intestinal canal; that the species 
infecting man does not infect other animals; that the 
eggs do not hatch in the intestinal canal; and that the 
larvae are not infectious until they are at least four or 
five days old. The real source of infection is, therefore, 
1 Dock and Bass, Hookworm Disease. 



TRANSMISSIBLE DISEASES 179 

found in the body wastes of individuals who are in- 
fected with the disease. 

The usual sequence of infection is as follows: The 
eggs from the worms in the human intestines reach the 
soil with the faeces, often as many as 1,700,000 eggs 
being passed in a single stool; the eggs hatch into larvae 
in the soil; the larvae pass through the skin (commonly 
through the feet) and reach the intestines; in the intes- 
tines the larvae develop into adult worms; the adult 
worms produce eggs, which in their turn are passed out 
of the body with the faeces. 

The general effect of the disease, when it is severe, is 
to produce an extreme degree of anaemia, with conse- 
quent loss of energy and mental alertness. In children 
growth is interfered with, so that a young man of 20 
years who has been infected since childhood is often no 
more developed than a boy of 12 or 13 years. In many 
of these cases of delayed development X-ray pictures 
of the hands show the same slow development of wrist 
bones and the ends of the long bones of the arm as 
that found in cases of retarded development due to 
other causes. 

Prevention. The all-important matter in hookworm 
disease is prevention. This is best carried out by the 
following procedures, as given by Dock: — 

(1) Stopping the danger of infection by exterminat- 
ing the mature worms in the bodies of human beings, 
in order to check the supply of eggs at the source. 

(2) Preventing the growth or existence of larvae in 
the places where they develop. 



180 HEALTH WORK IN THE SCHOOLS 

(3) Preventing infection by larvae that have devel- 
oped notwithstanding the efforts mentioned under 
(1) and (2). 

Fortunately it has been found an easy matter to 
cure this disease, and, after a preliminary treatment 
with "salts," a few doses of thymol usually completes 
the cure. 

10. Poliomyelitis (Infantile Paralysis) 

Little need be said in this book about this disease of 
childhood, for two reasons : first, it will rarely or never 
be identified at school; second, it fortunately affects 
children of school age less frequently than infants. 

Mode of transmission. Evidence is now available 
which indicates that the disease may be spread by the 
stable-fly. On the other hand, some investigations 
throw considerable doubt on this point. At any rate, 
the fly is a menace to health, whether of the stable 
or domestic variety, and should be eliminated from 
civilized communities. The secretions of the nose and 
mouth of infected children carry the disease, a fact to 
which attention has been directed in respect to most 
contagious diseases of children. 

Control. There is a division of opinion as to whether 
schools should be closed during an epidemic of infantile 
paralysis. Many modern hygienists claim that such a 
procedure is quite unnecessary and useless, while some 
others insist upon the prompt closing of the schools. 
In any event, absolute isolation is necessary. We know 
rather less about this disease than any other from which 



TRANSMISSIBLE DISEASES 181 

children suffer, and it remains to-day one of the mys- 
teries which medical science is attempting to solve, 
but one which, like most other disease mysteries, will 
no doubt soon yield to painstaking scientific investiga- 
tion. 

11. Epidemic Meningitis 

As epidemics of meningitis have occurred rather fre- 
quently in this country, teachers, nurses, and others 
who deal with school children ought to have some 
knowledge of it. It has been recognized in the United 
States since 1805, and at various periods since that 
time there have been many definite epidemics of the 
disease. 

According to Osier, epidemic meningitis is most pre- 
valent in winter and spring. The disease is primarily 
one of childhood, but young adults are sometimes 
affected. 

Contagion. While epidemic meningitis is distinctly 
transmissible, it does not spread in the same manner as 
does scarlet fever or measles, but more after the man- 
ner of pneumonia. In general it may be said that it is 
chiefly communicated through the secretions of the 
nose, mouth, and eyes. The organism causing the dis- 
ease has been known since 1887. 

Symptoms. The attack in the majority of cases is 
sudden. Sometimes there is abrupt severe headache, 
with fever, vomiting, and a fast pulse, followed by rig- 
idity of the neck and unconsciousness. Very acute at- 
tacks often begin with sudden dizziness, followed by 



182 HEALTH WOKK IN THE SCHOOLS 

vomiting and headache, after which fever occurs, and 
even delirium. 

While there is great variety in the mode of onset, it 
may be said that in the main the characteristic points 
are: — 

Suddenness of attack. 

Headache. 

Dizziness. 

Vomiting. 

Fever. 

Unconsciousness. 

Rapid pulse. 

Retraction of the head. 

Oscillation of the eyes. 

Sometimes an eruption. 

Complications. Infection of the ear is very common, 
and deafness often follows. Inflammation of various 
joints (arthritis) is common. Accumulation of fluid in 
the ventricles of the brain (hydrocephaly) sometimes 
results, causing permanent feeble-mindedness. 

Treatment. Flexner's serum is the only form of treat- 
ment for epidemic meningitis which offers much hope. 
Every case of this disease should be diagnosed early 
and given the Flexner treatment. 

12. Contagious Eye Diseases 1 

Attention has been called to the fact that children of 
school age are especially susceptible to general contag- 
ious diseases. This is also true of diseases affecting the 

1 In the preparation of this section the authors are indebted to 
Whitaker and Ray-Wiggin Company for permission to use certain 
material from Dr. Hoag's The Health Index of Children. 



TRANSMISSIBLE DISEASES 183 

eyes. The early recognition of these eye troubles is of 
very great importance, not only to the child afflicted, 
but also to his intimate associates. 

As a rule, a teacher is justified in excluding any 
child, or at least in insisting upon a certificate from a 
physician, whenever such child is found with evidence 
of discharging eyes, gluing of the eyelids, or reddening 
of their inner surfaces, accompanied with any marked 
sensitiveness to light. To assist the teacher, parent, or 
any one else who has not had the medical experience, 
to distinguish the different contagious diseases of the 
eye, the following brief description of their essential 
characteristics may prove useful. 

(a) Pink-eye (acute catarrhal conjunctivitis) 

This disease is of frequent occurrence among chil- 
dren, and spreads in a school rapidly. It is commonly 
carried by means of the common wash-basin, or towel, 
borrowed handkerchiefs, and the like. The child com- 
plains of smarting eyes, sensitiveness to light, and a 
sensation as though sand were in the eyes. The eyelids 
stick together at night, and there is often some visible 
discharge in the corners of the eyes between the lids. 
The small blood vessels in the white part of the eyes 
(sclera) and of the lining of the lids (conjunctiva) are 
very prominent. This results in very noticeable red- 
dening of the eyes. 

The disorder usually lasts from ten to fourteen days, 
but it may persist a much longer time. The trouble is 
easily cured if it is attended to at once. 



184 HEALTH WORK IN THE SCHOOLS 

(6) Gonorrheal conjunctivitis 

This serious disease of the eyes is often found in new- 
born children, but it may also occur in children of any 
age or in adults. It is caused by the germ of gonorrhoea. 
Indications of this disease are: — 

Intense inflammation of the eyelids. 
Profuse, thick, purulent discharge. 
Lids red and swollen. 
Usually intense pain. 
Marked aversion to light. 
Profuse flow of tears. 

This form of eye disease is most serious in its conse- 
quences, often causing blindness. It is highly contag- 
ious. For these reasons it ought to be recognized early, 
and receive immediate and skillful treatment. Fortu- 
nately, it is not extremely frequent among school chil- 
dren. The disease usually lasts from four to six weeks, 
but sometimes very much longer. The child must be 
kept carefully away from other children, and every 
precaution used to prevent contagion by means of tow- 
els, handkerchiefs, wash-basins, the fingers, etc. 

(c) Diphtheritic conjunctivitis 

This disease is due to the same germ as that which 
produces diphtheria in the throat or nose. It is very 
dangerous, but rather infrequent. Contagion is very 
easy, and therefore its early recognition is of the ut- 
most importance. The essential characteristics of this 
disease are: — 



TRANSMISSIBLE DISEASES 185 

Severe pain in the eyes. 

Eyelids tense and dark-colored. 

Discharge at first thin and scanty, later thick and puru- 
lent. 

A thick, tenacious, grayish membrane forms upon the 
inner surface of the eyelids which is very difficult to remove. 

The disease demands the same treatment as diph- 
theria of the throat, and the periods of exclusion and 
quarantine are of great importance. 

(d) Trachoma 

This is one of the most serious of all diseases of the 
eyes, being highly destructive and extremely likely to 
produce blindness. Trachoma is prevalent in certain 
foreign countries, especially in the Orient. In Califor- 
nia trachoma is most frequently found among Indians 
and Mexicans, sometimes, also, among the Japanese. 
It is extremely common among the Indians of Minne- 
sota. In the large cities of the East and Middle West 
the disease often occurs among the children of other 
nationalities, largely in the slums or poorer districts. 
As many as 17,000 cases have been discovered in the 
New York schools in one year. 

Children suffering from the disease must be imme- 
diately isolated, and kept so until recovery is complete. 
The principal characteristics of trachoma are: — 

Inflammation. This is not very intense, but there is con- 
siderable swelling of the lids, an aversion to light, and flow- 
ing of tears. 

The outer surface of the eyeball becomes roughened. 

The inner surface of the eyelids becomes covered with 



186 HEALTH WORK IN THE SCHOOLS 

small granules, not unlike boiled sago grains in appearance, 
and this produces what is called granular eyelids. 

The disease is extremely contagious through the dis- 
charge from the eyes. Towels, basins, handkerchiefs, 
etc., are the chief means of conveyance, but uncleanly 
habits, unhygienic surroundings, poor food, poverty, 
and the like, favor its development and spread. Strict 
quarantine against this malady must be established, 
and continued until all signs of discharge have ceased. 
Laboratory examinations should be made in all cases of 
suspected trachoma. 

Conclusions 

(1) All contagious eye diseases need to be recognized 
early. 

(2) Removal from school of children with such diseases 
is necessary. 

(3) Great care must be exercised to prevent contagion 
through — 

The common towel; 
The common basin; 
Handkerchiefs ; 
Dirty fingers; 
Bedclothing; 

Public bathing-suits, and, possibly, swimming- 
tanks. 



TRANSMISSIBLE DISEASES 187 

13. Contagious Diseases of the Skin 1 

(a) Scabies (the itch) 

A contagious skin disease, due to an animal para- 
site which burrows in the skin, causing intense itching 
and scratching. The disease usually begins upon the 
hands and arms, spreading over the whole body, but 
does not affect the face and scalp. Between the fingers, 
on the front of the wrist, at the bend of the elbows and 
near the arm -pits are favorite locations for the disease; 
but in persons of cleanly habits the disease may not 
show at all upon the hands, and its real nature is deter- 
mined only after a most thorough and careful examina- 
tion. There is great variation in the extent and sever- 
ity of this disease, lack of personal care and cleanliness 
always favoring its development. Scratching soon 
brings about an infection of the skin with some of the 
pus-producing germs, and the disease is then accom- 
panied by impetigo, a pus infection of the skin. 

Itch is very common, and, because of the great vari- 
ation in its severity, mild cases are often mistaken for 
hives, eczema, etc. All children who are scratching or 
have an irritation upon the skin should be examined 
for scabies. 

It is very important that all infected members of a 
family be treated till cured, else the disease is passed 
back and forth from one to another. It is also impor- 

1 With acknowledgments to a pamphlet on Medical Inspection by 
the Massachusetts Board of Education, and one by the Cincinnati 
City Board of Health, called Suggestions to Teachers. 



188 HEALTH WORK IN THE SCHOOLS 

tant that all underclothing, bedding, towels, and other 
things that come in contact with the body, be boiled 
when washed. All cases of scabies should be excluded 
from school until cured. 

(6) Pediculi capitis (head lice) 

An extremely common accident among children, 
either from wearing each others' hats and caps, or 
hanging them on each others' pegs, or from combs 
and brushes. No person should be blamed for having 
lice — only for keeping them. 

The irritation caused by vermin in the scalp leads to 
scratching, which in turn causes an inflammation of 
the skin of the neck and scalp. The skin then easily be- 
comes infected with some of the pus-producing germs, 
and large or small scabs and crusts are formed with the 
dried matter and blood. Along with this condition the 
glands back of the ears and in the neck become swollen, 
and may be very painful and tender. 

The condition of pediculosis is most easily detected 
by looking for the eggs (nits), which are fastened to the 
hair and are not readily brushed off. The condition is 
best treated by killing the living parasites with crude 
petroleum, and then getting rid of the nits. With boys, 
this is easy — a close hair-cut is all that is needed; 
with girls, by using a fine-toothed comb wet in alcohol 
or vinegar, which dissolves the attachment of the eggs 
to the hair. All combs and brushes must be carefully 
cleansed. 

The best way to eradicate lice from a school is to 



TRANSMISSIBLE DISEASES 189 

have the school nurses give the necessary treatments. 
This can be done at school, without any exclusions. If 
there are no school nurses, then children with pedicu- 
losis should be excluded from school until the heads 
are clean. In Massachusetts, parents who neglect or 
refuse to care for their children in this respect may be 
prosecuted under the compulsory attendance law. 

(c) Ringworm 

A parasitic disease of the skin and scalp. When it 
occurs upon the skin it yields readily to treatment; but 
upon the scalp it is extremely chronic. Ringworm of 
the skin usually appears on the face, hands, or arms — 
rarely upon the body — in rings of varying size. One 
or more, usually not widely separated, may be present 
at the same time. All ringed eruptions upon the skin 
should be examined for ringworm. 

When the disease attacks the scalp, the hairs fall 
or break off near the scalp, leaving dime-to-dollar- 
sized areas, nearly bald. The scalp in these areas is 
usually dry and somewhat scaly, but may be swollen 
and crusted. The disease spreads at the circumfer- 
ence of the area and new areas arise from scratching, 
etc. 

Another disease, somewhat like ringworm of the 
scalp, is known as "favus" — a disease much more 
common in Europe than America. In this disease quite 
abundant crusts of a yellowish color are present 
where the process is active. The roots of the hairs 
are killed, so that the loss of the hair from this disease 



190 HEALTH WORK IN THE SCHOOLS 

is permanent, a scar remaining when the condition 
is cured. 

Care must be taken to see that all combs and brushes 
are thoroughly cleansed, and to prevent children wear- 
ing each others' hats, caps, etc. Children with ring- 
worm of the skin may be treated at school by school 
nurses. Ringworm of the scalp was formerly dealt with 
by exclusion, or by segregation of the children in special 
classes. By the earlier tedious methods of treatment 
attendance at the "ringworm class" was sometimes 
necessary for many months, or even years. The new 
X-ray method is so much more expeditious that where 
this method is used the disease no longer presents any 
serious problem. 

(d) Impetigo 

A disease characterized by a few or many, large or 
small, flat or elevated, pustules or festers upon the skin. 
The condition is often secondary to irritation or itch- 
ing diseases of the skin (hives, lice, itch), and scratch- 
ing starts up a pus infection. 

The disease most often appears upon the face, neck, 
and hands; less often upon the body and scalp. The 
size of the spots varies very much, and they often run 
together to form on the face large superficial sores, cov- 
ered with thick, dirty, yellowish, or brown crusts. The 
disease is contagious, and often spread by towels and 
things handled. Children having impetigo should not 
be allowed to attend school until all sores are healed 
and the skin is smooth. 



TRANSMISSIBLE DISEASES 191 

General Summary 

Any of the following points ought to suggest the pos- 
sibility of some form of transmissible disease in chil- 
dren : — 

Flushed face. Persistent cough. 

Lassitude. Scratching. 

Vomiting. Sore throat. 

Eruption. Aches and pains. 

Red eyes. Headache. 

Watery eyes. Fever. 

Nasal discharge. Loss of appetite. 



192 TABLE V. COMMON TRANSMISSIBLE 



Principal early signs and symptoms 



Method of Infection 



O 



Begins like cold in the head, with 
feverishness, running nose, in- 
named and watery eyes, and 
sneezing; small crescented groups 
of mulberry-tinted spots appear 
about the third day; rash seen 
first on forehead and face. The 
rash varies with heat; may almost 
disappear if the air is cold, and 
come out again with warmth. 

Illness usually slight. Onset sud- 
den. Rash often first thing no- 
ticed; no cold in head. Usually 
have feverishness and sore throat, 
and the eyes may be inflamed. 
Rash something between measles 
and scarlet fever; variable. 

Sometimes begins with feverish- 
ness, but is usually very mild and 
without sign of fever. Rash ap- 
pears on second day as small 
pimples, which in about a day be- 
come filled with clear fluid. This 
fluid then becomes matter, the 
spot dries up, and the crust falls 
off. May have successive crops 
of rash until tenth day. 

The onset is usually sudden, with 
headache, languor, feverishness, 
sore throat, and often the child is 
sick at the stomach. Usually 
within twenty-four hours the 
rash appears, and is finely spot- 
ted, evenly diffused, and bright 
red. The rash is seen first on the 
neck and upper part of the chest, 
and lasts three to ten days, when 
it fades and the skin peels in 
scales, flakes, or even large pieces. 
The tongue becomes whitish, 
with bright red spots. The eyes 
are not watery or congested. 



Forced exhalation and 
discharges from nose 
and mouth. 



Forced exhalation and 
discharges from nose 
and mouth. 



Forced exhalation and 
crusts on the spots. 



Forced exhalation, 
and discharges from 
nose and mouth, par- 
ticles of skin, and dis- 
charges from supurat- 
ing glands or ears. 
Milk especially apt 
to convey infection. 



DISEASES OF SCHOOL CHILDREN 1 193 



Remarks 



Period of exclusion recom- 
mended 



After effects often severe. Period of 
greatest risk of infection, first three or 
four days, before the rash appears. 
May have repeated attacks. Great va- 
riation in type of disease. Often fatal. 



After effects slight. 



When children return, examine head for 
overlooked spots. All spots should have 
disappeared before child returns. A 
mild disease and seldom any after effects. 



Dangerous both during attack and from 
after effects. Great variation in type 
of disease. Slight attacks as infectious 
as severe ones. Many mild cases not 
diagnosed and many concealed. The 
peeling may last six to eight weeks. A 
second attack is rare. When scarlet 
fever is occurring in a school, all cases 
of sore throat should be sent home. 



Four to five weeks. 



Three weeks. 



Till all scabs have dis- 
appeared. 



Six to eight weeks, or 
until desquamation 
has ceased. 



> With acknowledgments to The Health Index 0/ Children (Hoag). 



194 COMMON TRANSMISSIBLE DISEASES 




•c 



Onset insidious; may be rapid or 
gradual. Typically sore throat, 
great weakness, and swelling of 
glands in the neck, about the 
angle of the jaw. The back of the 
throat, tonsils, or palate may 
show patches like pieces of yel- 
lowish-white kid. The most pro- 
nounced symptom is great debil- 
ity and lassitude, and there may 
be little else noticeable. There 
may be hardly any symptoms at 
all. 

Begins like cold in the head, with 
bronchitis and sore throat, and is 
a cough which is worse at night. 
Symptoms may at first be very 
mild. Characteristic " whooping ' ' 
cough develops in about a fort- 
night, and the spasm of cough- 
ing often ends with vomiting. 

Onset may be sudden, beginning 
with sickness and fever and pain 
about the angle of the jaw. The 
glands become swollen and tender, 
and the jaws stiff, and the saliva 
sticky. 

Begins with feverishness, pain in 
head, back, and limbs, and usu- 
ally cold in the head. 

Illness is usually well marked and 
the onset rather sudden, with 
feverishness, severe backache, 
and sickness. About third day a 
red rash of shot-like pimples, felt 
below the skin and seen first 
about the face and wrists. Spots 
develop in two days, then form 
little blisters, and in another two 
days become yellowish and filled 
with matter. Scabs then form, 
and these fall off about the four- 
teenth day. 



Forced exhalation and 
discharges from nose, 
mouth, and ears. 



Forced exhalation and 
discharges from nose 
and mouth. 



Forced exhalation and 
discharges from the 
nose and mouth. 



Forced exhalation and 
discharges from the 
nose and mouth. 



Forced exhalation; all 
discharges, and parti- 
cles of skin or scabs. 



OF SCHOOL CHILDREN.— Continued 



195 



Remarks 



Period of exclusion recom- 
mended 



Very dangerous both during attack and 
from after effects. When diphtheria is 
occurring in a school, all children suffer- 
ing from sore throat should be excluded. 
There is great variation of type, and 
mild cases are often not recognized, but 
are as infectious as severe cases. There 
is no immunity from further attacks. 
Membrane may occur in nose only. 



After effects often very severe, and the 
disease causes great debility. Relapses 
are apt to occur. Second attacks rare. 
Specially infectious for first week or 
two. If a child is sick after a bout of 
coughing, it is most probably suffering 
from whooping-cough. Great variation 
in type of disease. 



Seldom leaves after effects, 
tious. 



Very infec- 



Excessively infectious. After effects often 
very serious and accompanied with pros- 
tration and nervous disability. 

Is peculiarly infectious. When small- 
pox occurs in connection with a school 
or with any of the children's homes, an 
endeavor should be made to have all per- 
sons over seven years of age vaccinated. 
Cases of modified smallpox — in vaccin- 
ated persons — may be, and often arc, 
so slight as to escape detection. Fact 
of existence of disease may be concealed. 
Mild or modified smallpox as infectious 
as severe type. 



Six weeks, or until all 
diphtheritic germs 
have disappeared 
from cultures taken 
from throat. 



Two months, or until 
cough and vomiting 
cease. 



About a month. 



About three weeks. 



Till all scabs have dis- 
appeared. 



196 HEALTH WORK IN THE SCHOOLS 

SELECTED REFERENCES 

(Chapters ix, x, and xi) 

1. Bernhard, Dr. L. : " Zur Diphtheriebekampfung in den Schulen." 
Beiheft with Zt. f. Schulges., August, 1912, pp. 198-207. 

2. Bridge, Dr. Norman: Tuberculosis. 1912, 

* 3. Burgerstein u. Netolitzsky: Handbuch der Schulhygiene. 1912, 

pp. 421-62. 
4. Carruthers, Dr. A. : " Epidemic Poliomyeletis in West Suffolk." 
School Hygiene, 1912, pp. 94-101. 

* 5. Chapin, Dr. C. V.: Sources and Modes of Infection. 1910, pp. 

399. 

* 6. Cohn, Dr. M.: "Schulschluss u. Morbiditat an Masern, Schar- 

lach u. Diphtherie." Zt. f. Schulges., 1913, pp. 64 ff. 

* 7. Cornell, Dr. Walter S.: The Health and Medical Inspection of 

School Children, 1912, pp. 524-64. 

8. D'Ewart, John: "School Infectivity." The Child, 1912, pp. 
162-67. 

9. Dock and Bass: The Hookworm Disease. 

10. Dregalski, Dr. V.: "Bekampfung der ubertragbaren Krank- 
heiten in den Schulen." Beiheft with Zt. f. Schulges., August, 
1912, pp. 739-48. 

11. Eberstaller, Dr.: " Masern u. Schule." Inter. Mag. Sch. Hyg., 
vol. in, 1907, pp. 1-20. 

*12. Fairfield, Dr. Letitia: "School Influence on the Mortality from 

Scarlet Fever, Diphtheria and Measles." School Hygiene, 1911, 

pp. 549-53. 
*13. Gilmour, A.: "Measles and Child Welfare." The Child, 1913, 

pp. 352-60. 
*14. Gulick and Ayres: The Medical Inspection of Schools. 1913. 

(2d edition.) 

15. Harmon, N. Bishop: "Concerning Dirt." School Hygiene, 1910. 
pp. 74-81. 

16. Herrman, Charles: "Prevention of the Spread of Contagious 
Disease in Public Schools." Inter. Mag. Sch. Hyg., 1909, pp. 
1-16. 

17. Hill, Dr. Charles: The New Public Health. Minn. St. Board of 
Health. 

*18. Hoag, Dr.E.B.: The Health Index of Children. 1910. (Chapter 

IV -) 

19. Hoag and Hall: Bulletin of American Academy of Medicine, 

1911. 

20. Hogarth, Dr. A. H. : The Medical Inspection of Schools. 1909. 
(Chapter xm.) 

21. Hopf, Dr.: "Hygienische Bedeutung des Handewaschens." 
Zt.f. Schulges., 1906, pp. 154 ff. 

22. Hutchinson, Dr. Woods: Preventable Diseases. 1909. (Chapters 
x and xi.) 



TRANSMISSIBLE DISEASES 197 

23. Jacobi, Dr. A.: "Contagious Disease." Report of Fifth Congress 

of Am. Sch. Hyg. Assoc, 1911, pp. 51-58. 
*24. Kerr, Dr. James: (and others): "The Control of Measles." 
School Hygiene, 1913, pp. 131-69. 
25. Laser, Dr.: "Das Nagelbeissen der Schulkinder." Zt. f. 

Schulges., 190G, pp. 219/. 
*2C. Matheny, W. A.: "The Common Drinking-Cup." Ted. Sem., 
1911, pp. 205-14. (Contains bibliography of twenty-three 
titles.) 
27. Meylan, G. : " The Hygiene and Sanitation of Summer Camps." 
Report of Sixth Congress of Am. Sch. Hyg. Assoc, 1912, pp. 71- 
76. 
*28. Nice, Leonard B.: "The Disinfection of Books." Ped. Sem., 

1911, pp. 198-204. (Contains bibliography.) 
*29. Oker-Blom, Dr. Max: "Zur Bekiimpfung des Scharlachs in den 
Schulen." Inter. Mag. Sch. Hyg., 1912, pp. 516-28. 

30. Osier: Modern Medicine Series. 

31. Petruschky, Dr. J.: "Der Diphtherieschutz der Schulkinder." 
Beiheft with Zt. f. Schulges., August, 1912, pp. 177-88. 

32. Porter, Dr. Charles: School Hygiene and the Laws of Health, 
pp. 224-38. 

33. Pottenger, Dr. F. M.: Tubercidosis. 

*34. Poelschau, Dr. : " Ueber die Bekampfung der Masern durch die 
Schule." Beiheft with Zt.f. Schulges., August, 1912, pp. 162-77. 
35. Porter, Dr. Langley: Prevention of Tuberculosis in Children. 

*36. Rosenfeld, Dr. S.: "Schulbesuchsdaueru. Morbiditat." Zt.f. 
Schulges., 1906, pp. 472/. 

*37. Schulz, Dr.: "Ueber Klassenepidemien von Diphtheric" 

Beiheft with Zt. f. Schulges., August, 1912, pp. 188-98. 
38. Sequeira, Dr. J. H.: "The Treatment of Ringworm." School 
Hygiene, 1912, pp. 155-61. 

.39. Shaw, E. R. : School Hygiene. 1901. (Chapter xn.) 

*40. Von Sholly, Dr. Anna: "Trachoma; Its Prevalence and Treat- 
ment." Report of Sixth Congress Am. Sch. Hyg. Assoc, 1912, 
pp. 115-24. 
41. Toledano, Dr.: "La revaccination des enfants des ecoles." La 
Midecine Scolaire, 1912, pp. 113-25, and 162-76. 

*42. Williams, Dr. Lewis: "The Control of Contagious Diseases 
through the School Clinic." School Hygiene, May, 1910. 

*43. Newmayer, S. W.: Medical and Sanitary Inspection of Schools. 
1914, pp. 318. 

See also the Proceedings of the various International Congresses 
of School Hygiene, especially of 1913. 



CHAPTER XII 

OPEN-AIR SCHOOLS 

Recent spread 

The phenomenal spread of open-air schools during 
the last few years constitutes one of the most signif- 
icant developments in modern education. 1 The first 
open-air recovery school was that of Charlottenburg, 
Germany, in 1904. England's first school of this type 
was opened in 1907; America's first, in 1908. Since 
then, open-air schools for tuberculous or pre-tuber- 
culous children have been established in nearly all of 
the large cities of every country. There were open-air 
schools in forty -four cities of the United States in 1912. 
No city which has undertaken the work has subse- 
quently abandoned it. 

The school department of Boston has adopted the 
plan of building one or more open-air classrooms in 
each new school building to be erected. About 5 per 
cent of Boston's school population will attend these 
classes. In some of the cities and countries of Cali- 
fornia a majority of the school buildings now being 
erected are constructed on a plan which permits all 
the rooms to be converted in a moment into open-air 
rooms. This is done by means of hinged windows, 

1 For a comprehensive and interesting account of this entire move- 
ment, including data regarding management, cost, etc., the reader is 
referred to the admirable booklet by Leonard P. Ayres. 



OPEN-AIR SCHOOLS 199 

which reach from floor to ceiling, and which occupy 
practically all of the space of one or more of the walls. 
The open-air school has been conducted in the main 
for the benefit of tuberculous or pre-tuberculous chil- 
dren. Here such children are watched over by school 
nurses or medical attendants, fed from one to five 
meals of nourishing food per day, and given a daily 
program which resembles very little the study pro- 
gram of the ordinary school. The book work is usually 
reduced to two or three hours per day and the re- 
mainder of the time is devoted to manual work, play, 
meals, rest, and sleep. 

Program 

The following program of the Bradford (England) 
open-air school is typical : — 



9 A.M. 


Breakfast. 


9.45 to 10.45 


Ordinary school work. 


10.45 to 11 


Play. 


11 to 12 


Ordinary school work. 


12.30 to 1 


Dinner. 


1 to 2 P.M. 


Rest and sleep. 


2 to 3 


Play. 


3 to 4.30 


Outdoor lessons (nature study, 




geography, etc.). 


5 


Tea. 


5.30 to 6 


Play. 



In some of the open-air schools of Germany as many 
as five meals are served per day ; in the United States, 
more often from one to three. In some cases the amount 
of time devoted to instruction is less than that at Brad- 
ford, and the period for sleep proportionately longer. 



200 



HEALTH WORK IN THE SCHOOLS 



Results 

Tuberculous children who attend open-air classes 
seldom fail to show immediate and rapid improvement 
in weight, appetite, blood-count, mental alertness, 
and freedom from colds. At the Bostall Wood School 
(London), children gained on the average six and a 



Lbs. 


A.ug 


Sept. 


Ocfc 


Nov. 


4 


























S 

c 


shoo 
osec 


1 








3 
2 
1 














































































** 


*"' 


*'* 


.'" 


^** 


_,*'' 


.+' 


.**. 


."' 


>" 


*'• 


*"' 


.-*" 


-*"' 











FIG. 6 

Showing the average weekly gain or loss in weight of children attending the 
Bradford Open-Air School in 1908. The dotted line shows the average in- 
crease which takes place in the case of children under ordinary conditions. 




Mid-winter sun-baths at Leysin Hospital for children with tuberculosis of the bone. 




Pivot windows. Open-Air School. George Bancroft Building, Minneapolis. 
OPEN-AIR SCHOOLS 



OPEN-AIR SCHOOLS 201 

half pounds during the thirteen weeks the school was 
in session. The Charlottenburg school brought a 
similar increase in weight. In the first open-air school 
of Chicago the average gain per child was three and 
three quarter pounds during the first month. These 
gains are all much in excess of the normal. 

As a rule, the rapid gain in weight continues only 
so long as the school is in session. When vacation 
comes, and the child is thrown back upon the resources 
and regimen of the home, his progress toward recovery 
is checked or thwarted altogether. In the school year 
1910-11, the children of Open-Air School Number 21, 
New York City, lost during the Thanksgiving, Christ- 
mas, and Easter vacations an average of 1.72 pounds 
per child. This was 49 per cent of the average gain 
per child during the entire year. In one of the Cleve- 
land open-air schools (1910-11) the pupils made an 
average gain in weight of more than four and a half 
pounds between December 12 and January 9, while 
the pupils of a similar school, in the same city, required 
to be indoors during the same period on account of 
building repairs, suffered an average loss of one and 
a half pounds, notwithstanding the continuance of 
special feeding. 

The improvement in the condition of the blood is 
also very marked. Children who are placed in open-air 
classes are usually found to have a haemoglobin con- 
tent of about 70 per cent. Sometimes it is as low as 
50 or 60 per cent. Under the combined influence of 
outdoor instruction, feeding, decreased book-work, 



202 HEALTH WORK IN THE SCHOOLS 

and increase of rest and play, the haemoglobin seldom 
fails to mount rapidly to 80 or 85 per cent. This is 
within 5 or 10 per cent of normal for children of school 
age. At Bradford the average increase of haemoglobin 
during nine weeks was 10 per cent. For Open-Air 
School Number 21, New York City, the average gain 
per child from October to May was 13.75 per cent. 

Haemoglobin records, like those of weight, demon- 
strate the superiority of the open-air school over the 
average city home. This is clearly revealed in figure 7. 



/o 
84 

82 

80 

78 

76 

74 


J 3 J3 
° " ^ © t» P *1 ._• • .. . o S . ® 












/ \ 
f \ 

\ 

} 






































i 
\ 

\ 
\ 

\ 
t 




































% 

C 






































~\ 

\ 
\ 
\ 

\ 

1 






































\ 

























































FIG. 7 

Haemoglobin tests, Providence Open-Air School, 1908-1909. Average for 
class. Note falling off during vacation. 



OPEN-AIR SCHOOLS 



203 



Except for vacation disturbances, therefore, the 
haemoglobin improves under the open-air regimen 
throughout the school year. The gain is usually very 
rapid at first, then becomes somewhat slower as the 
normal condition is approached. 

It is interesting to compare with this the haemoglobin 
curve of normal children in the ordinary indoor class. 
Such a comparison was made in New York City, in 
1910-11, between 27 normal children of the regular 



90 
89 
88 
87 
86 
85 
84 

a 83 

2 82 
1 81 

1 80 
*S 79 
as 78 

77 
76 
75 
-74 
T8 
-72 
_. Jl 


rare — 

Oct. 


Nov. 


Dec. 


■ran — 

Jan. 


Feb. 


Mar. 


Apr. 


May 


June 








































8 




*»., 


















^ 




■ 
















^ 




£<% 


°<SV 










&A 


<0P 








81 






£< 


V 
















f 





































































FIG. 8 

Curves showing changes In haemoglobin during school year in anaemic chil- 
dren of Open-Air School No. 21, New York, and in normal ohildren 
chosen from an ordinary class. 



204 HEALTH WORK IN THE SCHOOLS 

class and the 21 sickly children of Open-Air School 
Number 21. The blood of normal children in the ordi- 
nary class was found to deteriorate gradually during 
the school year, while that of the open-air children 
significantly improved. 

In a seaside hospital in Germany, conducted as a 
six-weeks' summer-vacation colony for tuberculous 
children, Haberlin * has for several years made blood 
tests of children on arrival and on departure. The 
average gain of 81 pupils, 4 to 14 years of age, was 
452,000 red corpuscles per cubic millimeter of blood. 
The average gain in white corpuscles was 2000. 
Haemoglobin tests for 362 children gave an average 
increase of about 8 per cent. Twenty-eight children 
who were studied separately had an average haemo- 
globin content of 79 per cent on arrival in June, 92 
per cent on their departure after six weeks, 86 per 
cent the following December, and 84 per cent in 
February. Nineteen of the children were followed for 
two years. When these first entered the colony the 
haemoglobin averaged 75 per cent. In six weeks it 
rose to 88 per cent, and was 85 per cent when the 
pupils returned to the colony the following summer. 
This is important as showing that much of the good 
accomplished is a permanent gain. 

Haberlin found for 913 such children an average 

gain in chest circumference of 1.6 centimeters during 

the six weeks, and an average increase of 7.5 kilograms 

in strength of grip. The gain in weight was several 

1 See reference 10 at end of this chapter. 



OPEN-AIR SCHOOLS 205 

times the normal, and in the case of 74 per cent of the 
children was permanent. Many of these children, says 
Haberlin, are from good homes. Notwithstanding 
this, they are barely able, after their return home, to 
retain the advantage gained in the six weeks' summer 
colony. No further gain is made. But the same chil- 
dren, on their return to the colony the following sum- 
mer, immediately begin to gain at several times the 
normal rate. 

Appetite and sleep improve correspondingly. When 
Open- Air School Number 21 of New York began work 
in September, 1910, no child ate more than his regular 
allotment of food, and 20 per cent did not eat all that 
was served them. Within eight weeks all were eating 
their entire allotment, and 25 per cent of them were 
given a second helping. Sleep, which averaged for 
the first month only 12 minutes during the daily 
rest-hour, increased to 41 minutes by the end of the 
year. 

After a few months in the open-air school a large 
proportion of tuberculous children (usually from one 
third to one half) present the appearance of complete 
recovery, while most of the remainder show distinct 
improvement. Neither improvement nor apparent 
cure, however, justifies the return of the child to the 
indoor class. Relapse may occur. The mere fact that 
a tubercular tendency exists gives such a child an 
undeniable right to that type of school which will ac- 
complish most to strengthen his physical defenses. 



206 HEALTH WORK IN THE SCHOOLS 

Pedagogical results 

The mental results of the open-air school are hardly 
less important than the physical. Children who are 
listless, apathetic, and retarded may become interested 
and attentive. Nervous children develop habits of 
self-control. Incorrigible children become docile and 
helpful. The spirit of the open-air school is "differ- 
ent." Freedom, initiative, and social cooperation re- 
place the artificiality and routine of the usual school. 
Open-air schools tend to inculcate open-air morals. 

One of the best lessons of all relates to pedagogical 
economy. The open-air school has demonstrated that 
it is possible for sickly children to make as satisfactory 
school progress on a study program of three hours per 
day as healthy children ordinarily make on a five-hour 
program. In the New York school already referred 
to, 48 per cent of the pupils advanced at more than 
the normal rate. Grades in the open-air classes usually 
average better than in others. Attendance is nearly 
always more regular. It is not necessary for the child 
to become retarded while recovering from tuberculosis. 

The instruction, itself, in open-air classes has note- 
worthy advantages. The child is brought into closer 
relation with the world of animate and inanimate 
things around him, and is more likely to associate the 
knowledge gained in class with his own experiences. 
Arithmetic, for instance, is taught in the Charlotten- 
burg school by measuring objects, counting trees, 
calculating spaces, etc. In the geography classes re- 



^M 


■IK. 








■E 


> 
1 •. 


■■ 


^iinn 




■ \< 


«■ 


Hirot 


■m 


BB&- 


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^~^™ ■ 


VT 


iy 


;|pi re \ 9 jM 


r 


fr 


\ Hra ' 


■ 


y Kt^m 




■ i 


IBP 




i%vl«w^ 




v! F 


zzagj^ 




? •' vrgjw ^i.^<y t 


\\ flfl 




M^nE . 1 ■ . ■ v.t«/^Swa£! J->Jl 


■l 






. .... -' 


5 4 




I ' 


£| 



" a 

S I 

^ I 

S a. 

^ >> 

S5 A 




The monthly examination by the physician in charge. 




Complete relaxation on the cots. 

CHICAGO OPEN-AIR CLASSES 

From Kingsley's " Open-Air Crusaders," by permission of United Charities of Chicago. 



OPEN-AIR SCHOOLS 207 

lief maps are constructed in the sand showing the 
configuration of the surrounding country. The action 
of running water, the formation of deltas, the causes 
of floods, the modes of irrigation, etc., are all made 
clear by objective instruction. The habits of plants 
and animals, fundamental facts relating to the de- 
composition of rocks, soil formation, weather condi- 
tions, etc., are easily imparted and made intimate 
possessions of the child's mind. 

Open-air schools have so fully proved their superi- 
ority as to warrant their extension to include a con- 
siderable proportion of the school population. At least 
ten or fifteen per cent should be looked upon as def- 
initely predisposed to tuberculosis. Nor is there any 
valid argument for limiting the advantages of open- 
air schools to children who are sickly. Schools which 
accomplish so much for the latter could not fail to be 
of benefit to normal children. It is foolish to deny a 
healthful environment to all except those whose 
health is already impaired. 

REFERENCES ON OPEN-AIR SCHOOLS 

1. Austin, Gertrude: "Heliotherapy for Tuberculous Children." 

The Child, 1912, pp. 839-45. 
*2. Ayres, Leonard P.: Open-Air Schools. 1910, pp. 171. 

3. Baginsky, Adolph: "Ueber Waldschulen u. Walderholung- 
statten." Zt.f. piid. Psych., Path., u. Hygiene, 1906, pp. 161-77. 

4. Bienstock: "Die Waldschule in Mlihlhausen." Zt.f. Schulges., 
1908, pp. 219 ff. 

*5. Bruner, F. G.: "The Influence of Open Air and Low Tempera- 
ture on the Mental Alertness and Scholarship of Pupils." Proc. 
N.E.A., 1911, pp. 890-98. 
6. Clark, Ida: "Open-Air Schools in England and Germany." 
Kgn. Rev., 1910, pp. 462-09. 



208 HEALTH WORK IN THE SCHOOLS 

7. Crowley, Ralph: The Hygiene of School Life. 1910. (Chapter 

XIV.) 

*8. Curtis, Elnora: "Outdoor Schools." Ped. Sem., 1909, pp. 169- 

94. 
9. Godfring: "Die Waldschule f. Schwachbefahigte Kinder." Zt. 
f. Schulges., 1907, pp. 236 ff. 
*10. Haberlin, Dr. : " Die Blutarmut u. Skrof ulose der Kinder; ihre 
Folgenu. ihre Behandlung." Zt.f. Kinderforsch., 1911, pp. 1-8. 
11. Henderson, C. H., "Outdoor Schools." The World's Work, 
January, 1909. 
*12. Kingsley, Sherman C: Open-Air Crusaders. 1911, pp. 109. 
*13. De Montmorency, J. E.: "School Excursions and Vacation 
Schools." Special Rept. by London Board of Education, 1907, 
pp. 71. 

14. Spencer, Mrs. Anna: "Open- Air Schools." Rept. of Inter. 
Cong, of Tuberculosis, 1908, pp. 612-18. 

15. Taylor, D. M.: "Residential Open- Air Schools for Delicate 
children." The Child, 1912, pp. 846-54. 

16. Warner, Allan: "Open- Air Schools by the seaside." The Child, 
1912, pp. 826-38. 

*17. Watt: W. E.: Open Air. 1910, pp. 282. 
18. Williams, Ralph: "The Sheffield Open- Air Recovery School." 
School Hygiene, 1910, pp. 136-43. 



CHAPTER XIII 

SCHOOL HOUSEKEEPING 

School dust and its dangers 

Schoolrooms have too long been prisons for the 
incarceration of children and dust. Until recently, a 
school without its eternal cloud of dust was as in- 
conceivable as a school without children. However, 
with the advance of physiological and bacteriological 
science our ideals are undergoing a rapid change, and 
the modern canons of school hygiene are ever becom- 
ing more strict in regard to methods of insuring clean- 
liness. 

School cleanliness means chiefly the avoidance of 
dust. To carry on a constant warfare against this 
enemy of children we employ janitor service amount- 
ing to the full time of 30,000 or 40,000 men and women. 
Their monthly wages amount to more than the wages 
paid to our standing army. The enemy they fight 
is infinitely more menacing to our national welfare 
than the military forces of other nations. Directly 
and indirectly, dust probably causes greater destruc- 
tion of life in the United States every year than was 
accomplished by battle in any year of our Civil War. 
All nations employ naval and military experts at liberal 
salaries to study scientifically the means of defense 
and destruction in order that the forces of war may 



210 HEALTH WORK IN THE SCHOOLS 

be managed effectively. But nations do not employ 
dust experts. Few people know what constitutes 
efficient janitor service, or care enough about it to 
find out. Would not a national training school for 
janitors contribute more to humanity than do mili- 
tary and naval academies? 

Dust is of two kinds, organic and inorganic. Dust 
of some kind is omnipresent. On lofty mountain-tops 
or over the sea the number of dust particles per cubic 
centimeter of air may be as low as 150 or 200. In a 
garden near the center of Paris the number was 160,000 
per cubic centimeter. The air in a room where the 
Royal Scientific Society of Edinburgh met was found 
to contain 275,000 particles per cubic centimeter be- 
fore the meeting and 400,000 after an hour and a half. 
Near the ceiling there were 3,000,000 particles per 
cubic centimeter. 

But not all dust is injurious. If not metallic or 
gritty, inorganic dust particles may be breathed in 
great numbers without injury. Apart from germ- 
bearing particles, it is the gritty mineral dust that is 
most to be feared. Mineral dust produces its injury 
in two ways : (1) Numerous small particles lodge in the 
lungs and excite by their presence the formation 
around them of a fibrous tissue which replaces the 
true lung tissue; and (2) they produce lacerations of 
the throat and lungs which serve as lodging-places 
for disease germs, especially the tubercle bacilli. 
Laborers who grind pottery, and inhale thousands of 
sharp-edge dust particles with every breath, die with 



SCHOOL HOUSEKEEPING 211 

six times the normal frequency from tuberculosis. 
For the same reason, glass-workers and stone-cutters 
have a mortality from tuberculosis several times the 
normal. 

Mineral dust is abundant in all but the best-kept 
schoolrooms. It is (1) blown in by the dust-laden air 
from streets or roads; (2) carried in on the shoes of 
children as dirt and gravel, later to be ground and 
pulverized on the floor; and (3) manufactured in large 
quantities by the inordinate use of chalk and black- 
boards. Dust from all these sources is so dangerous 
that relentless warfare should be waged against it. 

Organic dust is dangerous principally as a germ- 
carrier, although air-borne germs do not play as great 
a role in causing infectious diseases as they were 
formerly thought to play. Nevertheless infections 
sometimes occur in this way, and hygiene demands 
that we should keep the number of organic dust parti- 
cles as low as possible. 

The amount of germ-carrying dust in a room is 
tested by exposing to the air, for a given time, a gela- 
tin plate of standard size and material, which catches 
the floating germs and acts as a culture medium for 
the development of bacterial colonies. The plate is 
then examined microscopically, and the number of 
bacterial colonies counted. 

The number collected on a plate is found to vary 
from none in purest mountain air to many hundreds 
in the worst ventilated dwellings, shops, and schools. 
In a children's drawing-room the number in a short 



212 HEALTH WORK IN THE SCHOOLS 

time was multiplied eight times by the dancing of 
twenty children. In railway coaches, bedrooms, 
schools, etc., the number increases rapidly the more 
persons there are crowded together, the more actively 
they move about, and the smaller the intake of pure 
air. 

The investigations of Camelry, Haldane, and Ander- 
son show that the number of germs carried by school- 
room air averages about ten times as great in the 
worst ventilated as in the best ventilated schools. 
Children are often exposed for six hours a day to an 
atmosphere which is five times as thick with germs 
as the ordinary bedroom in a middle-class home. It 
was found that the number of bacteria per liter of air 
in a Dundee high school could be raised from 10 to 
150, by having the pupils stamp on the floor. The 
number is always enormously increased by calisthenic 
exercises in the room, by the movements of children 
at recess, and by dry sweeping. Even a well- ventilated 
schoolroom, if dirty, has been found to contain more 
bacterial colonies than a one-room city dwelling, kept 
clean. 

Prevention of dust by means of floor oils 

Many experimental tests have demonstrated that 
floor oils are extremely effective, if applied correctly 
and often enough. The floor should first be cleaned 
thoroughly, the oil should be spread thin, and after 
drying the unabsorbed oil should be mopped up. 
Treatment should be given at least three days before 



SCHOOL HOUSEKEEPING 



213 



the room is to be used, and should be repeated at least 
two or three times yearly. 

The following table from Dr. Lambert, 1 which is a 
fair sample of numerous experiments of this kind, 
illustrates very well the effect of floor oil on the num- 
ber of germs in schoolroom air: — 

TABLE VI 





Colonies of bacteria 


Plates exposed 


Floors 
treated 
with oil 


Floors 

not 

treated 


5 minutes in still air 




2 
38 
11 

6 

1 


7 


30 minutes in still air 


12 


5 minutes during sweeping 


456 


5 minutes just after sweeping 

5 minutes beginning 10 minutes after sweeping 
5 minutes beginning 15 minutes after sweeping 


79 
62 
31 



Dr. Butler's tests (quoted by Lambert) show that 
the bacteria are no more numerous over an oiled floor 
after four weeks than over an untreated floor two days 
after scrubbing. In fact, the oil is very effective for 
twelve to fifteen weeks after its application. Other 
tests have shown that an old, worn floor is more hy- 
gienic when oiled than a new and well-laid floor un- 
treated. Oker-Blom has demonstrated that if a floor 
is properly treated with oil the amount of dust in the 
air after sweeping is less than is the case after the chil- 
dren have been permitted to run twice around the 
room in physical exercises. 2 

1 See reference 10 at the end of this chapter. 

2 See reference 12 at the end of this chapter. 



214 HEALTH WOEK IN THE SCHOOLS 

Against the use of oil it has been argued that it 
darkens the floors, makes them slippery, and causes 
the soiling of girls' dresses. These arguments have 
little weight. The darkening can be partly prevented 
by properly cleaning the floors before the oil is applied, 
and by wiping them every week with wet cloths. The 
floors will not be made slippery if the excess of oil is 
removed, nor will they, after the first few days, spot 
the dress very considerably. With the shorter dresses 
now worn, the skirt and the floor seldom come in con- 
tact. Pupils should be taught, anyway, that it is 
better and cleaner to have a little dirt on the dress 
than to mix it with the food which is given to the 
lungs. 

Method of cleaning 

The number of dust particles and germs also depends 
on the method of dirt removal. The least effective 
method is that of sweeping the dry floor with the old- 
fashioned straw broom. Only the coarse dirt, which, 
of course, is harmless because it could not reach the 
lungs, is removed in this way. The fine dirt, the only 
kind that can injure us, is mixed with the air. The 
bristle brush far excels the broom as an instrument of 
cleanliness, and is especially effective when used with 
dampened sawdust or other materials of like nature. 
Still better is the oil brush, an ordinary brush furn- 
ished with a small tank for kerosene. The kerosene 
slowly feeds down from the tank upon the bristles, 
keeping them slightly moist. When the floor is kept 



SCHOOL HOUSEKEEPING 215 

well oiled and brushes of this type are used, the dust 
practically disappears. 

It seems probable, however, that vacuum cleaners 
are destined to supersede all other methods in the 
care of schoolhouses, as they have done for office 
buildings, hotels, apartment houses, etc. Some hun- 
dreds of school buildings are already equipped with 
them, with a resulting noticeable decrease in sickness 
and improvement of attendance. 

Where primitive methods of sweeping are employed, 
dusting becomes an important feature in the care of 
the school building. The feather duster and the old- 
fashioned broom were fit companions in crime. Both 
have been driven from our city schools, but both 
continue their nefarious business in the rural dis- 
tricts. They should be outlawed relentlessly. The 
feather duster moves the dust, but does not re- 
move it. The only way to get rid of the dust 
which settles on the school furniture is to wipe it 
up with a damp cloth. No other dusting deserves 
the name, and any other kind is worse than none 
at all. 

Other ways of preventing dust 

We have already seen that floating dust is many 
times increased by the marching, stamping, and play 
of children in the room. Calisthenic exercises should 
be given out of doors, and, except when it cannot be 
avoided, children should not be permitted to remain 
indoors at recess time. Open windows let the fresh 



216 HEALTH WORK IN THE SCHOOLS 

air blow in and the dust blow out. The windows 
should be kept open during all recesses. 

As a rule, blackboards are used much more than is 
necessary. "Dustless" crayons are not quite dustless, 
but should replace the soft plaster-of-Paris chalks 
still so generally used. Better than chalk and black- 
board is the " muroscroll, " a paper surface which rolls 
in a wooden frame and is used with wax crayon. It 
is inexpensive, convenient, and while not rendering 
the blackboard entirely unnecessary, it can replace it 
for most purposes. 

Dust can be further prevented by proper cleanliness 
of the children in shoes, dress, and body. The schools 
should be provided with doormats of both the wire 
and fiber varieties. 

Special effort should be made to keep the gym- 
nasium clean. Children breathe more deeply there 
than in the classroom. Mats and other dust-gathering 
paraphernalia should be discarded. The windows 
should be kept open, and cleaning should be thorough 
and frequent. 

If the school building employs mechanical ventila- 
tion, care should be exercised to keep the fresh-air 
supply free from dust. The intake should not be near 
a street or a dusty playground. In many cases it is 
necessary to screen the air at the intake by letting it 
pass through a cloth filter, which is kept damp by the 
dropping of water upon it. 

The basement also deserves special mention, partic- 
ularly when it is used as a substitute for playgrounds. 



M 

1 

* 


, 


1 H 


mmm 



THE MUROSCROLL 



SCHOOL HOUSEKEEPING 



217 



It is almost always poorly ventilated, and is usually 
filled with fine mineral dust produced by the move- 
ment of children over the cement floors. If a real play- 
ground is impossible, it is often better to use the halls 
than the basement for this purpose. Chicago has re- 
cently abolished basement play, and other cities are 
rapidly following the example. The moral argument 
against the basement playground is as strong as the 
hygienic. 

Standards of cleanliness 

The low standard of cleanliness still prevailing in 
the care of the school is well brought out in an in- 
vestigation by the Russell Sage Foundation in 1911. 
By means of a questionnaire sent to our 1200 cities, 
reports were secured from 758 on this point. The main 
results are summarized in the table given below. It 

TABLE VII 



Frequency 



Daily 

Once in 2 days .... 
Once in three days. 

Weekly 

Once in 2 weeks . . . 
Once in 3 weeks . . . 

Monthly 

Once in 2 months. . 
Once in 3 months. . 
Once in 5 months. 

Once a year 

As needed 

Never 





Cities reporting 


Floors 


Floors 


Windows 


washed 


swept 


washed 


1 


574 


1 


1 


49 


1 


3 


86 





36 


6 


22 


27 


2 


8 


8 





5 


135 


2 


117 


50 


1 


84 


140 





139 


115 


2 


111 


57 





31 


68 


10 


139 


44. 





5 



218 HEALTH WORK IN THE SCHOOLS 

will be noted that less than one half wash the floors 
as often as once in three months, and that nearly 
10 per cent do not sweep oftener than once in 
three days. It is very probable that if data could 
be secured from the cities which failed to answer 
the questionnaire the figures would be still more 
shocking. 

The school cannot be kept sanitary unless it is 
thoroughly swept and dusted each school day. The 
sweeping should always be done with windows open 
and after the close of the school day. The dusting 
should be done in the morning, at least half an hour 
before the pupils assemble. If the floors have not been 
oil-dressed, damp sawdust or some other preparation 
should be used in sweeping. Untreated floors should 
be varnished once a year, and all cracks should be 
kept filled. In addition, the floors and all the furniture 
need to be thoroughly washed every few weeks. Win- 
dows also should be cleaned several times a year, to 
keep them more transparent. 

Copenhagen requires that the school furniture be 
washed at least once every fourteen days, the windows 
eight times a year, and the inside of the desks once a 
year. The floors must be cleaned daily, and dry 
sweeping and dry dusting are prohibited. These 
measures were instituted chiefly for the purpose of 
combating tuberculosis. 

Janitor service should not ordinarily be done by the 
pupils, but in case this cannot be avoided, only pupils 
of good physical constitution, and those who come 



SCHOOL HOUSEKEEPING 219 

from families untainted with tuberculosis, should be 
permitted to do the work. 

Professional training for janitors 

Efficient housekeeping in the school should be sub- 
stituted for our present haphazard janitor service. 
The school should be kept as clean as our best hospitals. 
Before this can be brought about, janitors will have 
to be better trained for the work they have to do. 
Too often janitors have nothing to recommend them 
except "poverty or political pull." The position of 
janitor is really a responsible one. No other individ- 
ual about the school building, unless it be the princi- 
pal, has so much influence over conditions which 
affect the health of the pupils. 

At present even the better class of janitors usually 
do this work by rule-of-thumb methods. This is be- 
cause they have received no instruction as regards 
the scientific principles which relate to their work. 
Instead of merely being able to operate a fan, etc., 
mechanically, the janitor ought to know why fresh 
air is needed. He should not only be willing to sweep 
and dust according to rules, but he should appreciate 
the dangers arising from bad methods of school 
housekeeping. He should not only be able to run the 
ventilating and heating apparatus when it is in order; 
he should also have the mechanical skill to make 
certain repairs and to locate defects. 

Such knowledge and skill do not come of themselves. 
Professional training courses are needed, along the 



220 HEALTH WORK IN THE SCHOOLS 

lines suggested by references 6, 8, and 13 at the end 
of this chapter. Courses of this type do not cost much 
in time or money, and the results are out of all pro- 
portion to either. It is vain to expect in janitors a love 
of cleanliness or a conscientious adherence to the rules 
laid down for them, if they do not appreciate the dan- 
gers of uncleanliness and the reasonableness of the 
rules. 1 

REFERENCES 

*1. Ayres, Leonard P.: "What American Cities are doing for the 
Health of School Children." Annals Am. Acad. Polit. and Soc. 
Sci., March, 1911. 

*2. Burgerstein, Leo: "The Main Problems of Schoolroom Sanita- 
tion and School Work." Ped. Sem., 1910, pp. 15-28. 

3. Burrage and Bailey: School Sanitation and Decoration. 1899. 

4. Burmeister, K.: "Ueber die Verwendung von Staubbindenden 
Fussbodenolen in Schulen." Inter. Mag. Sch. Hyg., 1905, pp. 
185-217. 

5. Cooley, R. L.: "The Vacuum Cleaning of Schoolhouses a Spe- 
cial Problem." Am. Sch. Board J., July, 1911, pp. 18-19. 

*6. Dresslar, F. B.: School Hygiene, 1913, pp. 344-63. 

7. Engels, Dr.: " Staubbindende Fussbodenole." Zt. f. Schulges., 
1903, pp. 349-72. 

8. Frost, W. D.: "Our Short Course for Janitors." Proc. N.E.A., 
1911, pp. 990-92. 

9. Furst, M.: "Ueber die Reinigung der Volkschulklassen." Zt. 
f. Schulges., 1903, pp. 441-47 and 545-67. 

*10. Lambert, John: "Preparations for the Prevention of Dust in 

Schools." The Child., January, 1912, pp. 279-89. 
*11. Macfie, R. G.: Air and Health. 1909, pp. 161-91. 
12. Oker-Blom, Max: "Diirfen die Schulkinder beim Kehren der 

Schulraume behilflich sein?" Inter. Mag. Sch. Hyg., 1912, pp. 

477-90. 
*13. Putnam, Dr. Helen: School Janitors, Mothers, and Health. 1913, 

pp. 201. 

1 See reference 6 for an ideal set of instructions for the use of 
janitors. 



CHAPTER XIV 

THE TEACHING OF HYGIENE: THE FIRST SIX GRADES 

Inculcating health habits 

Those who are interested in the subject of hy- 
giene and sanitation in schools, whether as students, 
teachers, or principals, ought to possess some def- 
inite knowledge of the fundamental ideas underly- 
ing the successful presentation of health principles 
to children. These principles of health are in fact 
relatively simple, but unfortunately almost no other 
subject in the public schools is so inadequately taught 
as hygiene. This condition is to be explained in part 
by the fact that teachers are themselves ordinarily 
poorly instructed in the subject; in part by the fact 
that the subject-matter is not directly applied to the 
real life of the pupil, and is therefore ineffective. 

There is a vast difference between instructing a 
child about principles pertaining to his health and 
inducing him to put such principles into action. The 
teacher's problem is mainly the latter one, and any 
method of instruction which fails in this respect is a 
failure altogether. 

We hear much about the health supervision of 
schools, physical education, and the like, but how 
often are these ideas associated with the proper 
methods of school sanitation and with efficient instruc- 



222 HEALTH WORK IN THE SCHOOLS 

tion of pupils in matters pertaining to personal health? 
The truth is that the various health problems in 
schools have not been sufficiently correlated, and 
therefore much waste of time and energy have re- 
sulted. 

The problems of school hygiene will never be solved 
in a satisfactory manner until the closely related 
factors entering into them are clearly apprehended 
and properly associated. Of these factors, that of 
hygiene teaching is one of the most fundamental. 
How shall health instruction be made efficient in the 
different grades, and to pupils of various ages and of 
different home conditions? It would seem self-evi- 
dent that the first requirement is that the instruction 
must be adapted to the pupil's powers of compre- 
hension, but this is the very requirement most often 
lost sight of. The adaptation of the subject-matter 
to the intellectual and social development of the child 
has been strangely, and one might almost say per- 
versely, neglected. Miniaturing a subject adapted 
to an adult mind does not necessarily bring it within 
the range of the child's comprehension. 

In the lowest grades, say from the first to the fifth 
inclusive, little formal instruction is necessary, but 
health habits must be established at this stage of 
the child's development. This can be successfully 
accomplished by regarding such habits as an im- 
portant part of the child's everyday life at school, 
and as far as possible in the home. From the time a 
child enters school, until he is about ten or eleven 



THE TEACHING OF HYGIENE 223 

years of age, it is a mistake to suppose that he is much 
influenced by explanations and reasons. His habits 
of life during this period ought to be largely auto- 
matic. Children of this age who learn successfully 
do so mostly by imitation and constant repetition. 

This is the age during which environment exerts 
its greatest influence, for the young child becomes a 
part of all that surrounds him. A child's character 
in most fundamental particulars is usually pretty well 
established by the time he is seven or eight years of 
age, if indeed not earlier. It is of the utmost impor- 
tance, therefore, to place young children in a proper 
health environment. This must find expression in 
the schoolroom, in the personal habits of the teacher 
herself, in the school associates of the child, and in 
the general conditions of the child's home. 

The rather common practice of attempting to in- 
struct very young pupils in such subjects as the 
effects of narcotics and stimulants, the physiological 
uses of food, the structure of the body, the functions 
of organs, the chemistry of the air, the nature of the 
blood, the growth of bacteria, and the methods by 
which they are spread, and the like, is so absurd as 
to seem past belief. Yet these are some of the many 
topics to be found mentioned in most courses of study 
for children in the lower grades, and in part required 
by the laws of the State. The young child's mind 
never fully grasps such abstract ideas. Information 
at this period, to be of value, must be concrete, def- 
inite, capable of being expressed at once in action, and 



224 HEALTH WOKK IN THE SCHOOLS 

stated in terms with which the boy or girl is already 
perfectly familiar. The child must be instructed how 
to do the right thing in health, rather than why to do 
it, just as the aim of moral education is to train us to 
do the right thing at the right moment without having 
to think. The right thing in health will be done by 
children only when they are so educated that they do 
not have to think about it. 

It is of no possible use to tell small children that 
dirty finger-nails may harbor disease bacteria, or for 
us to talk about germs at all. These little pupils may 
successfully repeat what is said to them about such 
matters, but such conceptions are never really grasped 
by the young child. The habit of clean hands and 
nails at school must be acquired by the child, not 
primarily because of the possible danger from disease 
germs on dirty hands, but because clean hands are 
arbitrarily desirable. And the same may be said of 
habits pertaining to clothing, shoes, the hair, the teeth, 
and various other personal matters. 

The kind of knowledge which is desirable at this 
age is that which expresses itself in useful action. It 
is not essential that young pupils, or most older ones, 
should learn much about the structure or anatomy 
of the body; nor is it necessary or desirable for any 
but relatively mature pupils to understand how the 
body does its work (its physiology). But even the 
very youngest children in the schools are not too young 
to begin to learn some simple but fundamental prin- 
ciples in respect to the care of the body, about some 



THE TEACHING OF HYGIENE 225 

of the things which interfere with its best action, and 
how to avoid them. This is true hygiene. 

The complete study of the human body is one of 
the most difficult of all subjects. No piece of ma- 
chinery, however complicated it may be, can compare 
with the body in this respect. But without attempt- 
ing to study any but its most obvious features of struc- 
ture and action, even very young children can under- 
stand enough about this human machine of ours to 
learn how to take the best care of it. It should be the 
purpose of hygiene instruction in schools "to help 
young people, who will be men and women before very 
long, to know the truth about common living, and to 
act on such knowledge." 

Health instruction in the first five grades 

As has already been indicated, no formal methods 
of instruction need be presented before the sixth grade. 
Instead, teaching effort ought to be concentrated 
upon the inculcation of health habits. 

One of the easiest and most effective methods for 
helping the pupil to form health habits at this time is 
that of "personal inspection." This need never prove 
embarrassing, either to the pupil or to the parent, and 
when properly conducted will be regarded, first, as a 
source of entertainment, and second, as a matter of 
personal pride, until at last health habits have become 
an inseparable part of the child's life. 

Children are not dirty because they prefer to be so, 
but because they are not taught the pleasure of cleanli- 



226 HEALTH WORK IN THE SCHOOLS 

ness. Nearly all the rooms of the lower grades in our 
grammar schools are offensive to the sense of smell, at 
least to the individual who has not had his olfactory 
sense perverted through constant abuse of it. This 
offensive odor is due in large part to dirty, neglected 
bodies and clothes. The first requirement is, there- 
fore, to inculcate the love of personal neatness and 
cleanliness. It goes without saying that the teacher 
herself must embody this principle before she attempts 
to impart it to her pupils. In some rare cases, however, 
the lesson will have to begin with the reformation of 
the personal habits of the teacher. 

Personal hygiene inspection by teacher and pupils 

The personal inspection of pupils must be adapted 
to the peculiar needs of individual conditions, but in 
the main may follow the method outlined below. 

The pupils themselves may be easily taught to take 
part in this inspection by the teacher appointing the 
one passing the best inspection to act as inspector of 
the rest of the class, for a given time. The complete 
inspection need not be introduced at once, but the 
pupils may be led very gradually into it, so that their 
interest will be aroused and their fears or prejudices 
overcome. Other points not mentioned in the outline 
here given may be introduced, at the discretion of the 
teacher, and in order to meet local requirements. 
Some points may, of course, be omitted for the same 
reason, but in general the plan here suggested will be 
found fairly satisfactory in the majority of schools. 



THE TEACHING OF HYGIENE 227 

It should be noted that in this personal hygiene in- 
spection the questions are asked so that the negative 
answers indicate the number of undesirable conditions 
existing. 

Daily inspection of pupils in the first five grades 

1. Are the hands clean? 

2. Is the face clean? 

3. Is the hair clean, well brushed, and cared for? 

4. Are the nails clean and neat? 

5. Do the teeth look clean? 

6. Has the toothbrush been used? 

7. Are the ears clean? 

8. Is the clothing neat and clean? 

9. Are the shoes neat, clean, and well fitting? 
10. Does the child have a handkerchief? 

Additional information to be obtained by the teacher, at intervals 

1. Is at least one window kept open in the bedroom at 
night? 

2. Does the child drink coffee? How much? 

3. Does he drink tea? How much? 

4. Does he always have breakfast? 

5. What does he usually eat? 

6. Does he always have lunch? 

7. What time does he go to bed? 

8. What time does he get up? 

9. Is he suitably clothed? 

10. How often does he bathe? 

11. Is he required to do any work for pay? What sort? 

12. Are the bowels evacuated daily? 

13. Has the child apparently any bad sex habits? 

14. Does the child use an individual toothbrush? 

15. Does the child visit a dentist at least once every year? 

In the grades one to five, inclusive, little need be 
done in the way of health instruction beyond the con- 
stant inculcation of health habits. In grades one and 



228 HEALTH WORK IN THE SCHOOLS 

two the simple daily inspection will be about all that 
will be necessary or indeed successful. 

Inculcating food habits 

Beginning with the third grade, when the average 
child will be about eight years old, some very simple 
talks about foods may be introduced. It will be pos- 
sible to discover what the child usually eats at each 
meal, what he brings to school for his lunch, etc. It will 
be possible to teach these little people that they must 
have a mixed diet, and to explain in common words 
what this means. 

Peculiar and undesirable food habits may be dis- 
covered and corrected at this time. The child of this 
age can be taught how properly to masticate his food . A 
visit to the domestic science department may be made, 
and the children instructed how and what to eat by 
means of some actual meals eaten there under obser- 
vation. Simple health stories will prove useful at this 
period in the child's education, such as may be found 
in Hall's Primer of Hygiene. These stories ought to be 
read and explained by the teacher, and not set as les- 
sons to be recited by the little pupils (a method which 
never accomplishes any good). Proper eating habits 
may be rather easily acquired at this time. If the child 
in the third grade learns how and what to eat, his in- 
struction in hygiene will have been quite satisfactory. 
Here again the explanation, or why, is entirely unneces- 
sary, and has little or nothing to do with the formation 
of good habits. 



THE TEACHING OF HYGIENE 229 

Other health habits may, of course, be formed at 
this age, and the teacher must use her judgment about 
what is most necessary to include under particular 
and peculiar conditions. This will depend largely 
upon the social status of the average pupil in her class. 

Vital topics of hygiene study for grades three to five 

The following tabulated suggestions are offered as 
helpful in instructing pupils from 9 to 12 years of 
age: — 

1. Make lists on the board of what a considerable number 
of pupils had for breakfast. 

2. From this make a list of the good foods, and another of 
the bad foods. 

3. Include in the desirable foods such things as milk, 
cocoa, well-cooked cereals, bacon, eggs, toast, bread 
and butter, cornbread, crackers, and fruit, — particu- 
larly baked apples and stewed prunes. 

4. Include in the undesirable foods such things as coffee, 
tea, hot breads and biscuits, doughnuts, and hot cakes 
of all kinds when used to the exclusion of other foods. 

5. Make a list of breakfasts which fail to include a suffi- 
cient variety of foods. 

6. Make a list of breakfasts which include a good variety 
of foods. 

7. Note how many children report breakfasts principally 
made up of coffee and bread; coffee and doughnuts; 
coffee and crackers; bread and syrup; or breakfasts 
which include only starchy foods, or exclusively meat 
foods. Learn how many have butter. Note how many 
children eat no breakfast. Find out what time the meal 
is eaten ; how long the child spends at breakfast ; whether 
the child sits at table when he has his breakfast. 

8. If necessary, try to get in touch with the parents of 
children who have inadequate or otherwise undesirable 
breakfasts. This may often be accomplished by the 



230 HEALTH WORK IN THE SCHOOLS 

school nurse, who sometimes works miracles in home 
reform. 
9. Simple talks on the care of teeth may now be introduced . 
They ought to be based upon actual conditions discov- 
ered in the class by the teacher in the daily and other 
inspections. 

10. Simple lessons on the value of good air may be intro- 
duced in the third grade and carried through the other 
grades. The young child is not interested in the mechan- 
ical processes of ventilation, but may easily be taught 
to value fresh air and to form a dislike for foul air. 
Teach the child at this time how to detect bad air by 
the sense of smell, and encourage him to observe in 
this way the conditions present at school and at home. 
Proper breathing habits may be profitably taught now, 
and the teacher will be surprised to discover how few 
children know how to breathe in the right way. 

11. The cleanliness of the schoolroom must be dwelt upon, 
and the children urged to take part in keeping it free 
from unnecessary dirt. 

If during the first five grades the daily personal and 
the general inspection at intervals be observed, and 
knowledge of good food, fresh air, and cleanliness of 
environment be insisted upon, the child will have 
formed the most fundamentally important habits of 
health. But the teacher must never forget that what 
she is teaching is not "lessons," but habits, and that, 
therefore, she must never fail to relate each and every 
part of her instruction to the daily life of the pupil. 

To sum up what the average pupil ought to have 
acquired by the time he has reached the sixth grade, 
we will say: — 

1. He ought to appear at school with reasonably clean 
hands, face, ears, and body. 

2. His clothes ought to be neat, and free from avoidable dirt. 



THE TEACHING OF HYGIENE 231 

3. His shoes ought to be reasonably clean, and well enough 
fitting to avoid injury to his feet. 

4. He must have acquired a love for fresh air, and an 
antipathy toward bad air. 

5. He must have learned by experience the value of a well- 
ventilated bedroom and schoolroom. 

6. He must have learned to eat properly, and to know in 
general what to eat and what not to eat. 

7. He must have learned to value not only cleanliness of 
person, but cleanliness of immediate environment. 

8. He must have learned how much to sleep, what time to 
go to bed, and what time to get up. 

9. He must have acquired the habit of evacuating his bow- 
els daily. 

10. He must have learned to value a clean mouth and clean 
teeth, to use his toothbrush daily, and to visit a dentist 
at least once a year. 

Teaching hygiene in the sixth grade 

Beginning with the sixth grade, the character of 
hygiene teaching should be considerably changed from 
that given in the earlier grades. One of the best meth- 
ods for presentation to children of this age (about 11 
or 12 years) is that which has been employed with re- 
markable success by the Health Department of New 
York City in its "Little Mother's League." 

Hygiene lessons dramatized 

Under the guidance of a skillful woman physician 
and school nurse, little girls of 10 to 12 years of age 
are taught simple, practical lessons in home hygiene, 
including such things as the care of milk, foods for 
babies and young children, the general care of babies, 
keeping the home clean, the value of fresh air, and 



232 HEALTH WORK IN THE SCHOOLS 

other useful lessons on the health of the home. Fol- 
lowing a lesson on a subject such as, for example, the 
care of milk, certain children (usually two) are ap- 
pointed to write a little drama and present it before 
the other members of the League. This method in- 
terests the children tremendously, and impresses the 
subject upon their minds more effectively than any- 
thing else could. One of the writers of this book wit- 
nessed such a play given by a division of the " Little 
Mother's League," of New York City, in the summer 
of 1911, and was greatly impressed with the value of 
this sort of health instruction. 

No attempt is made by the teachers to correct the 
phraseology of the actors in the play, but they are 
allowed to present the subject exactly in their own 
way. The only requirement on the part of the teach- 
ers is that the subject-matter shall be essentially cor- 
rect. This means that children teach other children in 
words of their own, an innovation in teaching which 
accounts for the wonderful and instant success which 
the method met as soon as it was introduced. This 
method may be easily adapted to classes in the public 
schools, and to mixed classes as well as to little girls 
alone. It seems rather remarkable that the most suc- 
cessful method ever devised for teaching useful health 
lessons to children of this age should have originated, 
not in the public schools, but in a great city health de- 
partment which has not ordinarily been looked upon 
as responsible for teaching of any sort. This is another 
illustration of the fact that some of the best methods 



THE TEACHING OF HYGIENE 233 

of teaching originate outside of school systems, and is 
in line with the growing demand of to-day that teach- 
ing methods and lesson materials be in touch with the 
real life of the everyday world. 

The efficient and conscientious teacher will at once 
grasp the wonderful possibilities of this kind of in- 
struction through play, and easily adapt it to all the 
practical needs of pupils of the sixth grade. 1 

Reading material may be employed at this time, if 
desired, although this is not in the least an essential 
requirement for any but the teacher who is devoid of 
initiative and interest in her subject. The writers 
would mildly protest against any required text for 
pupils of this grade, but would recommend supple- 
mentary reading, of which there is now fortunately 
available an abundance of the best sort. 

Outline of scheme for teaching hygiene in the sixth 
grade 

The following is a list of subjects from which selec- 
tions for discussion may be made by the teacher, and 
followed, in some cases, with appropriate supplement- 
ary reading by the pupils: — 

1. Care of milk. 

2. Handling of food at home, in bakeries, stores, markets, 
etc. 

3. Preparation of food. 

1 The Louisa Alcott School of Boston has carried this idea still 
further by the use of models of all kinds, which the children make. 
The exhibit of this school at the International Congress of Hygiene 
at Washington in 1912 was most impressive. 



234 HEALTH WORK IN THE SCHOOLS 

4. Preservation of food. 

5. Eating habits. 

6. Disposal of garbage. 

7. Pure water supplies. 

8. Disposal of sewage. 

9. Water and purification. 

10. Flies and their control. 

11. Mosquitoes and their control. 

12. Fresh air. 

(a) At home. 

(b) At school. 

(c) In factories, stores, theaters, churches, etc. 

13. The skin. 

14. The teeth. 

15. The eyes. 

16. The ears. 

17. The nose and throat. 

18. Colds. 

19. Headache. 

20. Personal habits. 

(a) Clothing. 
(6) The bowels. 

(c) Play exercise. 

(d) Sex habits. 

(e) Sleep. 
(/) Bathing. 
(g) Work. 
(h) Food. 

(i) Coffee, tea, tobacco, alcohol. 

Following the discussion and supplementary read- 
ing of the subjects indicated in the list given, pupils 
should be asked to make personal observations, re- 
port personal experiences, and in general should be 
encouraged to take an active part in the lessons. 
Technical explanations should be diligently avoided, 
and memory work discouraged. 

The teacher may now encourage the preparation 



THE TEACHING OF HYGIENE 235 

and presentation of health plays on certain profita- 
ble topics. For advice on this subject teachers are rec- 
ommended to correspond with the Division of Child 
Hygiene of the New York City Board of Health, 
requesting details as to the management of the "Lit- 
tle Mother's League." l 

1 For references, see p. 251. 



CHAPTER XV 

THE TEACHING OF HYGIENE: SEVENTH AND EIGHTH 
GRADES 

Early instruction must deal with the concrete 

When the pupil has passed into the seventh grade 
he is ready to begin the formal study of hygiene. Un- 
til this period he should have been occupied primarily 
in establishing proper health habits. If he has been 
led along the right educational paths he will have 
accomplished this object. It will now be possible to 
pay less attention to matters of personal health, and to 
concentrate attention more particularly upon matters 
of environment. At this time it will be possible and 
desirable to begin to instruct the pupil definitely about 
bacteria — what they are, what they do, how they are 
carried about. To attempt to do this before the child 
is about 12 or 13 years old will result in little real good. 

The young pupil must be confronted only with con- 
crete ideas, ideas rather closely related to his daily 
experiences. To attempt to present a subject which 
deals with the invisible world, as does the study of 
bacteria, is to violate one of the commonest principles 
of pedagogy, namely, that the child must be led 
gradually from the concrete to the abstract, from the 
known to the unknown. Beginning with the seventh 
grade, however, simple demonstrations, illustrating 



THE TEACHING OF HYGIENE 237 

the relation of germ life to the various processes of 
human life, may be successfully introduced. 

Focus attention upon health, rather than upon disease 

The teacher cannot, however, be too careful to avoid 
focusing attention too much upon disease. The whole 
object of hygiene in the schools must be to teach 
health, not disease. How to keep well and strong is 
the desired object at this time. The avoidance of dis- 
ease will naturally follow when the pupil is properly 
instructed in the simple principles of health. Several 
of our otherwise useful modern texts on hygiene for 
the schools err in this respect, with the result that a 
sensitive child is more likely to be impressed with the 
morbid rather than the wholesome in daily life. 

Some hygiene texts, in their laudable attempts to 
escape the errors, platitudes, and gross exaggerations 
of the older texts, have done nearly as much harm in 
too severely adhering to the pathological scientific 
discoveries of the day, while at the same time ignoring 
the fact that the child has not acquired any true per- 
spective which will enable him to view things in their 
proper proportions. People may be easily frightened 
by too much truth, or rather by truth presented at 
too acute an angle. All that is necessary and essential 
in matters pertaining to disease may, if done at the 
right time, be easily presented without in the least 
frightening the child. When taught in the right way, 
and opportunely, modern ideas of hygiene and sani- 
tation need never alarm any one. 



238 HEALTH WORK IN THE SCHOOLS 

Learning how to meet his environment constitutes, 
as Professor Huxley long ago said, a liberal education 
for the child. It is never ignorance, but knowledge, 
which leads to health, and therefore to happiness. 
Man has always been most afraid of those things 
which he does not understand. One need fear dis- 
ease far less when one really understands its nature 
and how easily it may usually be avoided. 

Before beginning the study of bacteria, the young 
student will do well first to observe some of the re- 
lated forms of life with which he is more familiar. For 
this nothing can serve a better purpose than common 
yeasts and molds. Every child knows what these are, 
but few know just how they grow and what they do. 

Practical instruction in bacteriology for the seventh and 
eighth grades 

For further suggestions and definite explanations 
the teacher is referred to Professor Conn's Bacteria, 
Yeasts, and Molds. None of the experiments given 
require any special training or technical skill, and 
therefore no teacher need feel discouraged from at- 
tempting to carry out the directions given. 

Apply the knowledge gained in the experiments on 

bacteria, yeasts, and molds to the keeping-power of 

various foods; to the condition of the air of various 

rooms; to the cleanliness of hands, etc. 1 

1 If the teacher is in California, she should apply to the State 
Hygiene Laboratory at Berkeley for a set of demonstration plates, 
illustrating the growth of bacteria. In connection with this topic the 
teacher should read Conn's Bacteria, Yeasts, and Molds (Ginn & Co.). 



THE TEACHING OF HYGIENE 239 

The teacher must make it very clear to the pupil 
that bacteria, yeasts, and molds are true plants, and 
therefore dependent upon similar conditions for their 
growth as plants of a higher nature. She must also 
let the pupil understand that, while most bacteria are 
perfectly harmless plants, disease bacteria are spread 
about in the same way as the harmless variety. 

Have the children note how colds spread in a room 
at school, and ask them to offer explanations. Apply 
the knowledge of colds to other forms of sickness. 
Ask for suggestions on the prevention of the spread of 
diseases. The value of general cleanliness, pure air, 
sunshine, clean food, pure water, and milk must be 
emphasized at this time. 

Let the pupil try to answer the following questions 
after having completed the study indicated in this 
section: — 

1. What is yeast? 

2. How does it get into food? 

3. What kind of food does it need for growth? 

4. How does it grow? 

5. Why does it make bread rise? 

6. What effect does heat have upon yeast? 

7. Why will yeast not grow in preserved fruit? 

8. What is required for the growth of molds? 

9. On what sorts of things do molds grow? 

10. How may the growth of molds be prevented? 

11. Where do molds come from? 

12. Where are bacteria found in greatest numbers? 

13. Why does boiled milk keep longer than raw milk? 

14. What sort of milk has the largest number of bacteria? 

15. What is a good test of clean milk? 

16. How do bacteria get into food? 

17. What kind of air has the greatest number of bacteria in it? 



240 HEALTH WORK IN THE SCHOOLS 

18. What kinds of things carry bacteria? 

19. How may food be kept from spoiling? 

20. How are disease bacteria spread from one person to 
another? 

Teaching hygiene by means of "sanitary surveys" 

Following a general study of bacteria, in the manner 
outlined in the preceding section, the pupil may now 
be interested in making "sanitary surveys" in his 
immediate neighborhood. The plan which follows is 
not given from the idea that it ought to be strictly 
followed, but merely for its suggestive value. Teachers 
must use their judgment in adapting it to varying 
school conditions. In some instances it will be neces- 
sary to simplify the questions; in other instances they 
may be considerably amplified. 

Schools in rural districts must have surveys ar- 
ranged for them which will meet the particular prob- 
lems of the country: city schools will present very 
different sorts of problems to solve. The object of 
these surveys is to get the pupil in touch with his own 
particular health environment, to induce him to be 
observant of actual conditions as he will find them on 
the way to and from school, at home, on the city 
streets, in the country, in the school building, at the 
dairy, and in the market or grocery store. 

People endure unsanitary conditions because they 
have never been taught anything better. Just as soon 
as they become really observant, they become intoler- 
ant of whatever is unwholesome. Sanitary education 
is of vastly more importance than sanitary legislation. 



THE TEACHING OF HYGIENE 241 

Pupils in school do not become interested in health 
through reading about it, any more than they suc- 
ceed in acquiring an interest in language through 
the study of technical grammar. Whatever the pupil 
acquires that is really worth while he gets by actual 
observation, practice, and action. 

Knowledge, to be of any value, must be put to use. 
The teacher who will make use of the survey plan, as 
suggested here, will be astonished at the results 
obtained, both in respect to the information gained 
and interest aroused in the pupil, and to the bene- 
ficial results reacting on the whole community. Such 
a plan recognizes the fact that the pupil is an embryo 
citizen, and seeks to prepare him for efficient citizen- 
ship in his own town or city. 

The following sanitary surveys are presented as 
generally suggestive of the possibilities in the study 
of a pupil's health environment : — 

1. Sanitary survey of a home. 

2. Sanitary survey of a market. 

3. Sanitary survey of a school. 

4. Sanitary survey of a bakery. 

5. Sanitary survey of a dairy. 



Sanitary survey of a home 



I. Location. 

1. Drainage. 

a. Is the house on raised ground? 

b. Is t he drainage carried oft' on all sides 
by natural or artificial drains? 



Yes 



No 



1 These surveys are lo be made with the aid of the teacher, and, 
if possible, the parents. 



242 HEALTH WORK IN THE SCHOOLS 



Sanitary survey of a home 



c. Are the grounds kept free from stag- 
nant water? 
II. Sunlight and ventilation. 

1. Has the house good exposure to the sun? 

2. Has it good exposure to the air? 

3. Are the rooms most used on the sunny 
side of the house? 

III. General interior. 

1. Upon entering the house does the air 
seem fresh and odorless? 

2. Is the house free from flies? 

3. Are there at least two outside windows 
to a room? 

4. Have they screens? 

5. Is the heating arrangement adequate 
for the size of the house? 

6. Does it furnish fresh air for ventilation? 

7. Is the number of occupants consistent 
with the size of the house? 

8. Is the plumbing modern and open? 

9. Are the lights placed so as to avoid a 
glare? 

10. Can the floor coverings be removed and 
easily cleaned? 

11. Has the feather duster been discarded? 

12. Are useless hangings and decorations 
avoided? 

13. Are the floors clean and smooth? 

14. Do the toilets have an outside window 
for light and ventilation? 

IV. Sleeping apartments. 

1. Are there fewer than three occupants to 
a room? 

2. Do the rooms receive sunlight, at least 
part of the day? 

3. Is the exposure such as to admit the 
most and best air? 

4. Are the windows open from the top and 
bottom at night? 



Yes 



No 



THE TEACHING OF HYGIENE 



243 



Sanitary survey of a home 



5. Is the bed placed in the air currents? 

6. Are rugs used in place of carpets? 

7. Are bed coverings frequently aired and 
cleaned? 

V. The kitchen. 

1. Are the windows well screened? 

2. Is there a cooler-closet or an ice-box? 

3. Is the stove well ventilated? 

4. Are the sink and drain-pipe kept per- 
fectly clean? 

5. Is the food kept under cover or screen? 

6. Is the source of milk supply known? 

7. Is the source of water supply known? 

8. Is the source of food supplies known? 

9. Is the filter cleaned out every day? 

10. Is the floor kept clean, and the floor and 
walls painted frequently? 

11. Is there a light dry room in which per- 
ishable articles of food may be stored? 

12. Is the ice-box frequently cleaned? 

13. Are there proper toilet facilities con- 
nected with the kitchen? 

14. Are clean hand-towels provided? 

15. Are the eating utensils of sick persons 
boiled? 

VI. The back yard. 

1. Are breeding-places for flies avoided? 

2. Are breeding-places for mosquitoes 
avoided? 

3. Is the yard kept free from rats and mice? 

4. If there is an outside privy, is it kept in a 
sanitary condition? 

5. If there is a cesspool, is it cleaned out 
when necessary? 

6. Are wells and cisterns protected from 
drainage from contaminated sources? 

7. Is the drinking-water known to be safe? 

8. Is the ground kept free from slops and 
all refuse and filth? 



Yes 



No 



244 HEALTH WORK IN THE SCHOOLS 



Sanitary survey of a meat market 



1. Is the market in a sanitary location? 

2. Is the building well constructed? 

3. Is the cellar rat-proof? 

4. Are the outhouses and stables sufficiently 
removed? 

5. Is barnyard refuse and market refuse fre- 
quently removed? 

6. Are the general premises clean? 

7. Are the meat scraps kept in metal cans? 

8. Are the premises free from rats? 

9. Are the floors of concrete, or other imper- 
vious material? 

10. Are the doors made to swing? 

11. Are windows and doors screened? 

12. Is the place free from flies? 

13. Are counters made of marble, or glass, or 
hard wood? 

14. Are they screened to prevent handling of 
meat? 

15. Are the refrigerators clean? 

16. Are clerks clean and healthy -looking? 

17. Are they well protected with clean aprons? 

18. Is all meat protected from flies and dust? 

19. Are tables, trucks, racks, refrigerators, 
refuse boxes, floors, and tools cleaned 

daily? 

20. Is the source of meat known? 

21. Is it federally inspected? 

22. Is it city inspected? 

23. Is the meat delivered in covered wagons, 
and kept carefully wrapped until it reaches 
the purchaser? 

24. Are the carcasses kept carefully wrapped 
while being transported to the market? 

25. Are the wagons clean? 

26. Are the refuse wagons covered? 



Yes 



THE TEACHING OF HYGIENE 



245 



Sanitary survey of a bakery 



I. Location and construction. 

1. Is the building in a sanitary location? 

2. Is it a sufficient distance from stables 
and outhouses? 

3. Is barnyard refuse frequently removed? 

4. Is the cellar rat-proof? 
II. The salesroom. 

1. Axe the doors screened? 

2. Are they double-hinged (swinging) ? 

3. Is the food kept covered under glass? 

4. Is the store clean and free from flies? 

5. Are the clerks protected by clean aprons ? 
in. The bakery. 

1. Is the dough mixed by machine? 

2. Are the floors of the bakery clean and dry? 

3. Is the bread wrapped before sending it 
out on the wagon? 

4. Has the baker or any of his employees 
tuberculosis, or any other contagious 
disease? 

5. Are they clean and careful in personal 
habits? 

6. Are pet animals kept out of the bakery? 

7. Is there night-work in the bakery? 

8. Is the ceiling free from dirt and cobwebs ? 

9. Is the ventilation good? 

10. Are there windows enough? 

11. Are the storage facilities good? 

12. Are there toilets? 

13. Are they properly located? 

14. Is there a place for people to wash their 
hands? 

15. Are individual towels used? 

16. Is the bakery free from cockroaches 
and other vermin? 

17. Are utensils and machines kept clean? 

18. Are flies kept out? 

19. Is garbage kept covered in metal cans? 

20. Is it frequently removed? 



Yes No 



246 HEALTH WORK IN THE SCHOOLS 



Sanitary survey of a school 



I. Ventilation. 

1. Are the rooms well ventilated? 

2. Does the air smell clean and fresh? 

3. Is there some method for humidifying 
the air? 

4. Are the rooms well aired at recess? 
II. Lighting. 

1. Are the rooms evenly lighted? 

2. Is the window area at least one fifth of 
the floor area? 

3. Are the desks so placed as never to face 
direct sunlight? 

4. Are dark window-shades avoided? 

5. Are yellow or linen-colored shades or 
Venetian blinds used? 

6. Is the tinting of the walls light? 

7. Is the ceiling lighter than the walls? 

8. Is over-decoration avoided? 

9. Does all the light come from one side, 
the left? 

10. Is there eight feet of space between the 
front wall and the first window? 

11 . Does the light enter the room from the 
east or west? 

12. Do the windows reach within a foot of 
the ceiling? 

13. Are the seats in the darkest side of the 
room no farther than twenty-four feet 
from the windows ? 

DH. Temperature. 

1. Is the temperature kept over 65 degrees, 
and less than 70 degrees? 

2. Is there a thermometer in each room? 

3. Is a daily temperature chart kept in 
each room? 

IV. Cleaning and sweeping. 

1. Has the feather duster been discarded? 

2. Is a damp cloth used for cleaning up dust? 



Yes 



THE TEACHING OF HYGIENE 



247 



Sanitary survey of a school 



3. Are the windows washed at least three 
times a year? 

4. Has dry sweeping been abolished? 

5. Is oiled sawdust used on the floors when 
sweeping is done? 

6. Are the floors oiled at least twice a year? 

7. Are the floors free from sticky oil? 

8. Are the rooms well aired at the time of 
cleaning? 

9. Are the desks and all articles of furniture 
kept constantly clean? 

10. Are desks re-dressed at least every two 
years? 

11. Are desks washed with a disinfectant 
when necessary? 

12. Is the common use of articles which 
might carry infection avoided? 

V. The pupils themselves. 

1. Are pupils required to keep their hands 
and faces clean? 

2. Is the clothing of the pupils reasonably 
clean? 

3. Are pupils with poor eyesight seated 
near the front? 

4. Are deaf pupils seated near the front? 

5. Are pupils with skin diseases excluded? 

6. Are pupils with any contagious disease 
excluded. 

7. Is there any health supervision of pu- 
pils? 

Is there a school nurse? 
Do the teachers make any physical 
examinations of pupils? 
Is hygiene taught? How is it taught? 
Are the desks adjustable? 

12. Are they adjusted to the pupils? 

VI. General sanitation. 

1. Are paper towels provided? 



Yes No 



8. 
9. 

10. 
11. 



248 HEALTH WORK IN THE SCHOOLS 



Sanitary survey of a school 



Yes 



No 



2. Is liquid soap provided? 

3. Are there any shower-baths? 

4. Are drinking-fountains provided? 

5. Is the common drinking-cup abolished? 

6. Has the roller-towel been abolished? 

7. Has the common hand-towel been abol- 
ished? 

8. Is there a comfortable lunch-room for 
pupils. 

9. Is there a comfortable rest-room for 
teachers? 

10. Is there a "first-aid " emergency outfit 
supplied? 

11. Does anybody know how to use it? 

12. Are toilets clean? 

13. Are toilet-rooms well ventilated? 

14. Are toilets kept flushed? 

15. Is the basement light and clean? 

16. Are the school grounds kept perfectly 
clean? 

17. Is the drinking-water safe to use? 

18. Has any investigation of the water been 
made? 

19. Are ventilated coat-closets provided? 

20. Is fire drill practiced frequently? 



Sanitary survey of a dairy 



I. The barn. 

1. If made of wood, are the walls fre- 
quently whitewashed? 

2. Are walls and ceilings kept clear of 
cobwebs? 

3. Are windows so located as to prevent 
direct drafts on the animals? 

4. Is the barn well ventilated? 

5. Are floors made moisture-proof? 

6. Are gutters (preferably of cement) 
provided behind the stalls? 



THE TEACHING OF HYGIENE 



249 



Sanitary survey of a dairy 



Yes 



No 



7. Do they drain properly? 

8. Are the stalls kept clean? 

9. Are ceilings dust-proof? 

10. Is a clean wash-room provided for the 
milkers? 

11. Are paper or individual towels fur- 
nished? 

12. Is the roller-towel abolished? 

13. Is liquid soap provided? 
n. The milk-house. 

1. Is there a milk-house separated from 
the barn, and used for no other pur- 
pose? 

2. Is it clean? 

3. Is it screened? 

4. Is it provided with a cement floor? 

5. Are flies kept out? 

6. Is it cool? 

7. Is the milk kept covered? 

8. Is the milk cooled to at least 50 de- 
grees? 

HI. The utensils. 

1. Are all utensils kept clean? 

2. Are pails, cans, and bottles and other 
utensils steamed or boiled before 
using? 

3. Are all utensils which have been ex- 
posed in a house where there has been a 
contagious disease carefully sterilized? 

4. Is the patent milk-pail with cover 
used? 

5. Is the milk milked through gauze? 

6. Is the gauze always boiled and dried 
before using? 

IV. The premises. 

1. Is manure removed at least once a 
week? 

2. Are domestic animals kept away from 
the premises at the time of milking? 



250 HEALTH WORK IN THE SCHOOLS 



Sanitary survey of a dairy 


Yes 


No 


V. 


The surroundings. 

1. Is the barnyard clean and well 
drained? 

2. Are outhouses well removed from the 
vicinity of the barn and milk-house? 

3. Are sheds provided for animals? 

4. Is the water supply safe? 

5. Is the well (if any) so situated that no 
contamination can occur from a privy 
or other source? 

6. Is all sewage contamination of water 
supply avoided? 

7. Are garbage and manure prevented 
from accumulating? 

8. Are breeding-places for flies avoided? 






VI. 


The animals. 

1. Are the cows kept clean? 

2. Are the cows tuberculin-tested? 

3.' Are all the cows with any suspicion of 
disease kept away from the others? 

4. Are cows kept away from sewage- 
infected streams? 






vn. 


The milkers. 

1. Do milkers wear clean, special milk- 
ing-suits? 

2. Do milkers keep their hands clean? 

3. Are all milkers in good health? 

4. Are milkers who have been in associa- 
tion with cases of transmissible dis- 
eases kept away until danger is past? 






VIII. 


The "bunk-house." 

1. If a house for milkers is provided, is it 
kept clean? 

2. Is it well ventilated? 

3. Is there a suitable wash-room? 

4. Are the beds clean? x 







1 It is not expected that every dairy, and especially those in rural 
districts, will come up to the ideal suggested here, but they should 
approximate it in all essential matters. 



THE TEACHING OF HYGIENE 251 

HELPS FOR THE TEACHING OF HYGIENE IN THE 
GRADES 

Allen, William: Civics and Health. 1909, pp. 411. Ginn & Co. 

Denison, Elsa: Helping School Children. 1913, pp. 352. Harper & 
Bros. 

Hoag, E. B.: Health Studies. 1909, pp. 223. D. C. Heath & Co. 

Hoag, E. B.: Health Pamphlets for Schools. Whi taker and Ray- 
Wiggin Co., San Francisco. 

Hutchinson, Woods: We and Our Children (for teacher and parent). 
Houghton Mifflin Co. 

Hutchinson, Woods: Hutchinson's Health Series. Houghton 
Mifflin Co. 

Putnam, Dr. Helen: Report of the Committee on the Teaching of 
Hygiene in Public Schools. Bulletin of American Academy of 
Medicine, 1905, pp. 1-64. Easton, Pa. 

Ritchie and Caldwell: Primer of Hygiene and Primer of Sanitation. 
World Book Co. 

Tolman and Guthrie: Hygiene for the Worker. American Book Co. 

Wood and Reesor: Health Instruction in the Elementary Schools. 
1912, pp. 140. Published by Teachers College, Columbia Univer- 
sity, New York City. 

See also: Bulletin of American Academy of Medicine, October, 1912. 
A symposium on the teaching of hygiene. (Several excellent pa- 
pers.) Easton, Pa. 



CHAPTER XVI 

THE TEACHING OF HYGIENE: EDUCATION WITH 
REFERENCE TO SEX 

The problem 

Every teacher should have a true conception of 
the frequency with which ignorance of the laws of sex 
is responsible for sickness, misery, and death, indus- 
trial inefficiency, the infection of the innocent, and 
life-wreckages of many other kinds. The economic 
losses accruing from such ignorance doubtless exceed 
many millions of dollars annually in the United States 
alone, while the more important ethical and moral 
losses are of course not measurable at all. An ade- 
quate discussion of this aspect of the problem would 
lead us beyond the limits of the present chapter, and 
the reader is accordingly referred to the judicious 
treatments of the subject by Stanley Hall, Dr. Prince 
Morrow, and Professor Henderson. 1 As a rule even 
intelligent, well-educated persons are not well enough 
acquainted with either the moral or the hygienic im- 
portance of the problem. 2 

1 See references at end of this chapter. 

2 Searching investigations made by our most reliable authorities 
have revealed the fact that the prevalence of social diseases is far 
greater than most of us have believed. It is estimated that at least 
60 per cent of the males in this country have contracted the "red 
plague" (gonorrhoea) at least once, and that 2,000,000 of our people, 



EDUCATION WITH REFERENCE TO SEX 253 

Need of safeguarding school children 

Another aspect of the problem, touching the school 
even more directly, is the question of improper sexual 
conduct among children in the upper grades and high 
school. In even the best regulated, coeducational high 
school there is almost always a greater or less under- 
current of interests and events which are unwhole- 
some even when they are not positively immoral. 
Sometimes only a very few of the pupils are involved, 

many of them innocent women and children, are victims of the 
"black plague " (syphilis). Over one third of these are innocently 
infected. Reliable statistics indicate that each year about 10 per 
cent of the entire adult male population of the large cities are treated 
for one or the other of these diseases. In a city like New York this 
amounts to almost a quarter of a million cases annually, or more 
than seven times as many as the number of cases of diphtheria, scar- 
let fever, smallpox, measles, and chickenpox combined. Morrow 
estimates that 20 per cent of the venereal infection is acquired before 
the twenty-first birthday. Of the million boys who arrive at puberty 
annually in the United States, not far from half are venereally diseased 
within a few years. 

These conditions are not peculiar to the United States, but are 
common to practically the entire civilized world. Thus, in Germany, 
of the 8,500,000 persons included in the industrial insurance regula- 
tions, 500,000 each year receive sick benefits from this cause. This 
is about 6 per cent of the enrollment. The proportion for waitresses 
rises to 13.5 per cent, for young salesmen to 16.4 per cent, and for 
university students to 25 per cent. For a study of the moral condi- 
tions in American colleges the reader is referred to Birdseye. (See 
reference 3 at end of this chapter.) 

It is now quite well known that about one third of all blindness, 
and 80 per cent of congenital blindness, is due to ophthalmia neona- 
torum, or venereal infection of the child's eyes during birth. The 
social diseases are responsible also for about one half of the internal 
surgical operations which women undergo, for perhaps half of the ster- 
ility, and for about 15 to 20 per cent of the admissions to our insane 
hospitals. 



254 HEALTH WORK IN THE SCHOOLS 

sometimes many; children from the "best homes" 
hardly less often than others. 

Teachers and school officers too often rest in strange 
ignorance of things which pass before their very eyes. 
Often they are indignant if the problem is even called 
to their attention, blind, it would seem, to the very 
existence of this most imperious and most pervading 
of all human instincts. But when overt immorality 
among their pupils stands unmistakably revealed, 
these same persons are the ones most likely to turn 
with heartless severity upon the offenders, to banish 
them from the school as "degenerates. " In such cases 
one or two pupils are made the scapegoats and ex- 
pelled, as though to vindicate the honor of the school 
and to reestablish the self-respect of those who are 
responsible for its reputation. The inhuman and un- 
sympathetic treatment sometimes meted out to such 
offenders, who may be mere children and sinned 
against rather than sinning, would be impossible in 
any man who had not completely forgotten the storm 
and fire of his own adolescense. 1 

We should avoid alike the folly which ignores the 
evils and the cruelty which combats them with heart- 
less punishment and other summary measures. We 
must consent to face honestly and without prudery or 

1 " Of all cultivated classes, educators alone remain timid and in- 
active. . . . Teachers, who have the rarest opportunity to observe, 
have learned nothing and ignore the truth." (Stanley Hall.) 

" The very persons to whom to-day we have to look to effect the 
sexual enlightenment of children are themselves, to a great extent, 
also in need of enlightenment." (Albert Moll.) 



EDUCATION WITH REFERENCE TO SEX 255 

hypocrisy the actual situation : the fact that in most 
boys and in many girls the sexual emotions do not 
lie dormant until the traits of will and character have 
developed sufficiently for their proper control; the 
fact that very few boys and not all girls reach manhood 
or womanhood without at least for a time falling vic- 
tims to reprehensible practices or conduct; the fact 
that many children from homes otherwise admir- 
able have been so poorly instructed that their ideas 
of sexual matters are sufficiently grotesque and dis- 
torted to render almost any kind of conduct on their 
part pardonable and pitiable. 

The entire world is at last awakening to the serious- 
ness of the problem. In almost every civilized coun- 
try active organizations have been effected for the 
purpose of combating the evils by means of social, 
penal, and industrial reforms, and by more thorough- 
going enlightenment of the young. 

The school's relation to sex-education 

The relation of the school to the entire problem of 
sex-education is fairly well indicated by the expres- 
sions of belief regarding the following propositions, 
submitted in 1012 by the American Federation of Sex 
Hygiene to leading educators, physicians, and public 
men in various parts of the country. About one hundred 
replies were received, for the most part from just those 
persons who by virtue of their interest and experience 
are best entitled to a respectful hearing on the subject. 
The propositions and votes thereon are as follows: — 



256 HEALTH WORK IN THE SCHOOLS 

Proposition I 
The well-known facts concerning the widespread igno- 
rance, misunderstanding, and misuse of the human sexual 
function point clearly to the need of special instruction of 
young people in the scientific principles of sex. 

Affirmative, 91; negative, 0; doubtful, 5. 

Proposition II 
As it is well established that few parents are both quali- 
fied and willing to give their children this vital instruction, 
it is necessary that such instruction be given in the public 
schools, both elementary and high, in colleges, and in other 
organized educational agencies. 

Affirmative, 73; negative, 7; doubtful, 11. 

Proposition III 
The scientific basis of sex-instruction should be laid in the 
biological nature-study of elementary schools and the bio- 
logical courses of higher schools and colleges. Beginning 
with the nature-study lessons of the primary grades, life- 
histories of living things should be emphasized. In the ad- 
vanced nature-study of the grammar grades and the biology 
courses of the high school there should be a gradual presen- 
tation of the leading biological facts of animal and plant 
reproduction. It should also be incorporated in courses in 
hygiene and in ethics. 

Affirmative, 80; negative, 3; doubtful, 3. 

Proposition IV 
Specific instruction applying the biological facts to human 
life is needed, preferably at the end of the biology course in 
the early years of high school. 

Affirmative, 75; negative, 1; doubtful, 2. 

Proposition V 
Since numerous pupils never reach the high school, there 
is need of some definitely organized instruction relating to 
human life for pupils of grammar-school ages. This is the 
most difficult problem now apparent. 

Affirmative, 73; negative, 6; doubtful, 9. 



EDUCATION WITH REFERENCE TO SEX 257 

Proposition VI 
Provision should be made for sex-instruction in evening 
schools, in forms adapted to the needs of various types of 
students. 

Affirmative, 72 negative, 1 ; doubtful, 2. 

Proposition VII 
In order to appreciate the problems and cooperate with 
special teachers all teachers should know the fundamental 
biological, hygienic, and ethical facts relating to sex-proc- 
esses. To this end, teachers' training-schools should offer 
courses of biology and selected reading which give the needed 
knowledge. 

Affirmative, 82; negative, 0; doubtful, 8. 

Proposition VIII 
While the nature-study and biology classes may be coedu- 
cational, as abundant experience has proved, the special 
application of biological facts to human life should be in 
separate classes. 

Affirmative, 82 negative, 0; doubtful, 5. 

Proposition IX 
Special lectures under the auspices of clubs, churches, and 
other associations interested in general education should be 
established in order that the sex-education movement may 
reach parents and young people who are not connected with 
schools. 

Affirmative, 86; negative, 0; doubtful, 0. 

Proposition X 
The above propositions refer to instruction in normal sex- 
processes. Such instructions should obviously be made basal. 
But, at the proper time, instruction should be given also as 
to: (1) the danger of unnatural and unhygienic sex-habits; 
(2) licentious or irregular sexual indulgence; (3) and later, the 
impressive facts relating to the dangers of social diseases, 
and the consequences to themselves and others. Instruction 
in regard to the last two should be given only to the upper 
classes of the high school and to students in college, by care- 



258 HEALTH WORK IN THE SCHOOLS 

fully selected instructors, preferably by those with, special 
training in medicine or physiology, and at the same time pos- 
sessing tact and skill; but all teachers should be prepared to 
help individual students who may need advice. 

Affirmative, 85; negative, 3; doubtful, 2. 

Proposition XI 
While instruction concerning abnormal conditions is largely 
a problem relating to adolescents, some direction of individ- 
uals is sadly needed by many children in the two or three pre- 
adolescent years; and it is to be hoped that every school will 
finally have one or more competent persons (principal, nurse, 
doctor, or teacher) able to deal effectively with the individ- 
uals needing help. 

Affirmative, 81; negative, 0; doubtful, 5. 

Proposition XII 
The introduction of sex-instruction into the public educa- 
tional system should be made carefully, and with due regard 
to local conditions, such as the attitude of school officials, 
public opinion, and the availability of specially trained 
teachers. Nothing could be more undesirable than precipi- 
tate introduction of sex-instruction by propagandic legisla- 
tors, or by over-zealous school officials. Far better results 
are to be expected if the teachers and parents interested in 
each school are first awakened to the need of special instruc- 
tion; and then the work should be developed gradually, 
quietly, conservatively, and on a sure foundation. 
Affirmative, 90; negative, 0; doubtful, 4. 

As to the need of some kind of education of the 
young with reference to sex perhaps every reader will 
agree with the authorities quoted. We cannot, even if 
we would, keep the child long in the innocence which 
rests upon ignorance. The child's interests in matters 
of sex are far more precocious and far more intense 
than appears on the surface. If the information which 
is sought is not gained from sources that are reliable 



EDUCATION WITH REFERENCE TO SEX 259 

and pure, it will be found in sources that are less desir- 
able. There is no third possibility. The "conspiracy 
of silence" has always and everywhere proved an 
utter failure. 

Special considerations relating to sex education 

The points on which disagreement arises have mainly 
to do with (1) the proper place for the instruction to 
be given, whether in the school or at home; (2) the 
content of such instruction; (3) the method of ap- 
proach; and (4) its appropriate time in the life of the 
child. These questions can be answered only with an 
understanding of their relations to each other, and in 
the light of certain general principles. The subject is 
too difficult to make dogmatism safe. The following, 
however, are important considerations: — 

(a) The purpose of sex-education should not be too 
narrowly conceived. The end cannot be attained by a 
few "sex-talks," stating bluntly the facts of the sex- 
life and painting in lurid colors the evil results of trans- 
gressions. The purpose of such education is much 
farther-reaching, and involves, indeed, the gradual 
shaping of the child's attitude toward fundamental 
ethical values, the patient molding of a whole char- 
acter. 

(6) We must clearly understand also that knowl- 
edge, alone, does not meet the requirements of this 
kind of education. Mere information, however exact, 
does not insure right conduct. The problem is less one 
of enlightenment than of moral education. The will 



260 HEALTH WOKK IN THE SCHOOLS 

must be made the master of the instincts. To rein- 
force the will, the "thou shalt not" needs to be re- 
placed by the uplifting power of inspiring ideals, intel- 
lectual enthusiasms, and wholesome respect for the 
integrity of body and mind. The life needs to be filled 
so full of good work and wholesome play that super- 
fluous energy will not seek improper outlets. The 
sexual instinct is not to be so much repressed as sub' 
limated; its energies directed to secondary channels 
and transformed into higher values. 

(c) The school needs to lay greater emphasis upon 
the broader relations of moral education, which should 
be interpreted to include training in social cooperation, 
acquaintance with social and civic responsibilities, the 
inculcation of habits of personal hygiene, respect for 
the body and pride in its capacities, love of outdoor 
life and sports, notions of chivalry, preference for good 
literature, a taste for music and art, etc. Nor can the 
school itself be an effective agent in moral education 
until its own moral dangers are frankly recognized. 
To overwork the device of emulation; to lay the stress 
upon getting ahead of others; to neglect the multi- 
tudinous opportunities offered by the school for prac- 
tical training in social duties and responsibilities; to 
divorce the teaching of history and civics from all ref- 
erence to modern social and industrial environment; 
to herd adolescent boys and girls promiscuously in 
crowded schoolrooms and narrow hallways where inti- 
mate physical contact is possible or unavoidable; to 
neglect the careful chaperonage of school children on 



EDUCATION WITH REFERENCE TO SEX 261 

social occasions, school picnics, etc. ; to induce conges- 
tion of blood in the pelvic regions by five or six hours 
of sedentary work, unrelieved by physical activity; to 
treat all reference to sex problems with prudery and 
repression: — all of these mistakes lay a burden of 
guilt upon the school which it cannot without hypoc- 
risy deny. When the school has cleared itself from all 
blame in these particulars, and has set a thoroughly 
wholesome environment for the adolescent boy and 
girl, it will be in better position to campaign for the 
cooperation of parents for the sex-education of chil- 
dren. 

(d) Sex-pedagogy differs in one fundamental par- 
ticular from the pedagogy of any other subject; it 
must not seek to create special interest in the material 
presented. For this reason, vague allusions which 
excite curiosity, and pictures, charts, or diagrams 
which center attention upon the physiological proc- 
esses of reproduction, are to be avoided. Some of the 
booklets prepared by well-meaning but unpedagogical 
enthusiasts, and designed for the use of the pupil, are 
thoroughly vicious in this respect. 

(e) Wherever the special instruction is given, 
whether in the home or the school, timeliness must be 
observed. Too early instruction may create the vices 
it seeks to prevent. The greater danger, however, is 
that the instruction best suited for each period of de- 
velopment will be unduly delayed. 1 

1 "Better a year too early than an hour too late" has been the 
slogan of the reformers. 



262 HEALTH WORK IN THE SCHOOLS 

On account of the age element, mass instruction in 
sex-hygiene by school grades is always indefensible. 
A fourth-grade class will usually be found to contain 
children all the way from 8 to 13 years of age. A sixth- 
grade class may range from 10 to 15 years, or an eighth- 
grade class from 12 to 17. For sex-instruction chil- 
dren should always be classified by ages, not by grades. 

(/) It is questionable whether mass instruction by 
means of "sex-talks," unrelated to other lines of in- 
struction, should ever be permitted, even when the 
pupils are classified on an age basis. Children of the 
same age may differ very greatly in physiological ma- 
turity, in the amount of sex-information they already 
possess, in innocence, and in their emotional reaction 
to the instruction given. The sudden presentation of 
the brutal facts of sex is almost sure to prove a nervous 
shock to some children, in whom it may give rise to 
morbid ruminations, phobias, etc. 

(g) Just here lies the great danger in exaggerating 
the evils of solitary vices. The views commonly held 
by teachers and other intelligent people on this point 
are colored by the extravagant exaggerations depicted 
in the literature disseminated by quack doctors. If 
the teacher learns that a feeble-minded or weakly or 
incorrigible child in her class is guilty of such practices, 
she is likely to conclude that the defect or perversity 
is due solely to the bad habit. It is now universally 
admitted by the best medical authorities that the 
evils of solitary vice are in most cases confined prin- 
cipally to their indirect effect upon morals, self-respect, 



EDUCATION WITH REFERENCE TO SEX 263 

etc., and to the resulting shame, worry, and other 
morbid ruminations. Nothing but evil can come out 
of scare-literature or scare-instruction. Quartering 
people alive in the sight of the public did not stop 
crime, nor will the horrible and essentially untruthful 
depictions of the evils of impurity lead children into 
paths of morality; what it will do is to drive a good 
many of them to the verge of insanity. 

Methods and content of instruction by stages 

Much experimentation will be necessary to deter- 
mine the proper content and the most effective meth- 
ods of sex-education. Our present knowledge and ex- 
perience, however, justify the following tentative out- 
line, which is offered purely for whatever suggestive 
value it may have: — 

One to six years. No instruction is necessary in the 
first half of this period, but habits of cleanliness should 
begin. Sleep, diet, bathing, etc., are very important. 
Care should be exercised with regard to choice of 
nurse. Male infants should be circumcised. Innocent 
habits of unnecessary touching and handling should 
be guarded against. 

At this period the trait of frankness may become 
deeply implanted in the child's nature, or its growth 
may be prevented or delayed. Extreme punishments 
breed cowardice and destroy confidence. As soon as 
the child's curiosity awakens regarding the origin of 
babies, he should be told the truth, in language simple 
and unevasive. This will usually occur about the age of 



264 HEALTH WORK IN THE SCHOOLS 

four or five years. The instruction at this point need not 
include the facts about paternal relationship, because 
the child has not yet begun to wonder about this. 

Six to twelve years. In the first half of this period 
the teaching of nature-study should acquaint the child 
gradually with the processes of reproduction in plants. 
The function of flowers, pollen, and seed, and the 
method of fertilization should be made thoroughly 
familiar. 

The program for the second half of this period 
should include similar study of typical animals below 
mammals, — fish, birds, insects, etc. Nature-study, 
in the broad sense, should be given a liberal share of 
the program, and the instruction above suggested 
could be related in such a way to the general processes 
of nature, and so gradually and opportunely intro- 
duced, that the needed information will be assimilated 
without attracting morbid attention to sex as such. 
Indeed, the child will not be consciously aware that he 
is receiving sex-instruction. 

Sometime during this period, probably between the 
ages of seven and ten, the child will need to be in- 
formed, in a general way, regarding the relation of 
father to offspring. The exact time and the exact ex- 
tent of the information needed will depend entirely 
upon the child's spontaneous curiosity. 

Indiscriminate warnings against improper habits 
should not be indulged in, but children known to have 
formed bad habits should receive private instruction. 
Here, as elsewhere, the idea should be to make virtue 



EDUCATION WITH REFERENCE TO SEX 265 

attractive by instilling ideals of cleanliness, strength, 
manliness, chivalry, etc. 

Twelve to fifteen or sixteen. The biological and hy- 
gienic phases of the nature-study program may now 
receive still further emphasis. The study of animals 
may be extended to include mammals, the function of 
the ovum, modes of fertilization, etc. The broader 
ethical implications should be stressed, the necessity 
for care of the young, the evolution of mother love, the 
significance of family life for the species, etc. As before, 
this will be incidentally woven in with the rest of the 
course, though its applications to human life can be 
made somewhat more explicit than in the earlier stages. 
Because of the prevailing attitude toward sexual mat- 
ters it may be advisable, where possible, to present 
mammalian zoology to boys and girls in separate 
classes. 

More special sex-instruction at this period is also of 
prime importance. Well before the phenomena of 
puberty make their appearance, both boys and girls 
should know the natural developments that may be 
expected and their appropriate hygiene. It is shame- 
ful and inexcusable that so large a proportion of chil- 
dren reach maturity without any such instruction 
whatever. This, no doubt, helps to account for a fact 
which several studies have reliably established, — that 
from 25 to 50 per cent of women suffer from menstrual 
disorders. With boys, emphasis should be placed upon 
the absolute normality of emissions during sleep, and 
upon the normality and healthfulness of continence. 



266 HEALTH WORK IN THE SCHOOLS 

Fifteen, and beyond. The teaching of biology should 
here be amplified to include the chief laws of heredity, 
human physiology with special reference to hygiene, 
the bacterial origin of disease and the modes of trans- 
mission, eugenics, etc. For the first time full particu- 
lars may be given regarding the consequences of ven- 
ereal infection, with special emphasis on the dangers to 
which innocent women and children may be exposed. 

The education of adolescent girls should everywhere 
include extensive training in household science, and in 
the hygiene of physical and mental development. 
Education for motherhood should be its conscious and 
avowed purpose. 

Summarizing, we may say: — 

(1) That sex-education should be individualized 
and adapted both in method and content to the child's 
stage of development and to his expanding curiosity. 

(2) It will be mainly of two kinds; general and spe- 
cial. The general includes the broad foundation laid 
by the extensive courses in nature-study and biology. 
The special includes the direct instruction about sex- 
ual phenomena, both normal and morbid. These two 
types of instruction will not necessarily be kept entirely 
separate. Indeed, the value of the special instruction 
will depend largely upon the degree to which it is made 
an integral and logical part of the whole process of 
biological enlightenment. 

(3) Sex-education must never be considered as an 
isolated problem, but as one related to the whole ques- 
tion of moral educatioD. Its success will always depend 



EDUCATION WITH REFERENCE TO SEX 267 

on the degree to which it is supported by high ideals, 
wholesome enthusiasms, and a right attitude toward 
the social world in general. 

Divided responsibility of the home and school in 
sex-education 

We are now in better position to say where sex-edu- 
cation belongs. It is obvious that the instruction we 
have designated as general, the biological founda- 
tion, should be given in the school. It belongs ther,e 
because the average parent has neither the time nor 
the equipment necessary to give it. The school has 
the time and can equip itself for the work by the in- 
troduction of laboratory methods into the elementary 
school, and by extending the training of teachers in 
hygiene and biology. 

It is equally evident that the instruction designated 
as special belongs partly in the home and partly in the 
school. The more personal and intimate its nature, the 
more such instruction becomes the proper function of 
the home. However, a great deal even of the special 
instruction can and should be woven in with the school 
work in nature-study and biology, and when parents 
are known to be entirely neglectful of their duties in 
this respect there is no alternative but for the school to 
assume the entire responsibility for the child's sexual 
enlightenment. 

The school should make every effort to enlist the 
cooperation of parents by means of popular lectures to 
parent-teacher associations, conferences with parents 



268 HEALTH WORK IN THE SCHOOLS 

in special cases, etc. Rightly prepared pamphlets ex- 
plaining the need of sex-education, indicating what 
such instruction should include and when it should be 
given, etc., would, no doubt, perform a great service. 
It is strange that this method has been so little used in 
this country. 

Finally, the complexity of the problem should re- 
mind us of the many-sided cooperation which will be 
demanded for its satisfactory solution. We may men- 
tion, for example, its relation to the alcohol question, 
to the social control of prostitution, to industrial 
methods, to poverty, to public recreation, to religion, 
to law, to housing, to newspapers, to divorce, to child- 
dependency and child-labor, to the reform of medical 
practice, to coeducation, school retardation, feeble- 
mindedness, etc. 

SELECTED REFERENCES 

(Recent literature on this subject is voluminous. Only a few of the 
most important references are given here.) 

*1. Addams, Jane: A New Conscience and an Ancient Evil. 1912, 
pp. 219. 

2. Bell, Sanford: "A Preliminary Study of the Emotion of Love 
between the Sexes." Am. J. Psych., 1902, pp. 325-54. 

3. Birdseye, C. F. : Reorganization of Our Colleges. 1909, pp. 410. 
(See pp. 118-45.) 

4. Cabot, R. C: "The Consecration of the Affections." Fifth 
Cong. Amer. Sch. Hyg. Assoc, 1911, pp. 114-20. 

*5. Eddy, Walter H.: "An Experiment in Teaching Sex-Hygiene." 

J. Ed. Psych., October, 1911, pp. 451-58. 
6. Eliot, Charles W.: "School Instruction in Sex-Hygiene." Fifth 

Cong. Amer. Sch. Hyg. Assoc, 1911, pp. 22-26. 
*7. Ellis, Havelock: Studies in the Psychology of Sex. Vol. vi. (See 
especially chapter n, "Sexual Education"; and chapter in, 
" Sexual Education and Nakedness.") 
8. Foster, W. S.: "School Instruction in Matters of Sex." J. Ed. 
Psych., 1911, pp. 440-50. 



EDUCATION WITH REFERENCE TO SEX 269 

9. Freud, Sigmund: Three Contributions to the Sexual Theory. 
Nervous and Mental Diseases Monograph Series, no. 7, New 
York, 1910, pp. 91. 
10a. Hall, W. S. : From Youth to Manhood. 

*10b. Hall, Stanley: Educational Problems. 1911. (See vol. i, pp. 
388-539. This is the broadest and most scholarly treatment of 
the subjects yet published.) 

*11. Henderson, Charles R.: "Education with Reference to Sex." 
Eighth Year-Book of the Nat' I Society for the Scientific Study of 
Education. (Part i, "Pathological, Economic and Social As- 
pects," pp. 74. Part n, "Agencies and Methods," pp. 89.) 

12. Hodge, C. F.: "Instruction in Social Hygiene in the Public 
School." Bull. Amer. Acad. Med., 1910, pp. 506-17. (See other 
papers of the symposium in same number.) 

13. Jung, C. G.: "The Association Method." Am. J. Psych., 

1910, pp. 201-69. 

14. Kongress der deutschen Gesellschaft zur Behdmpfung der Ge- 
schlechtskrankheiten, Sexualpadogogik. Leipzig, 1907, pp. 321. 

15. Mckeever, William A.: "Instructing the Young in Regard to 
Sex." Home Training Bull., no. 8, Manhattan, Kansas, pp. 16. 

*16. Moll, Dr. Albert: The Sexual Life of the Child. Translated by 
Paul, 1912, pp.339. (See pp. 179-219, " Importance of the Sex- 
ual Life of the Child "; and pp. 246-325, "Sexual Education.") 

*17. Morrow, Dr. Prince: Social Diseases and Marriage. 1904. 

18. Parkinson, W. D.: "Sex and Education." Ed. Rev., January, 

1911, pp. 42-59. 

19. Putnam, Dr. Helen: "Education for Parenthood." Education 

1911, pp. 

*20. Report of the Special Committee on the Matter and Methods of Sex 
Education; Amer. Federation for Sex Hygiene, New York. 

1912, pp. 34. 

21. Schmitt, Clara: "The Teaching of the Facts of Sex in the Public 
Schools." Ped. Sem., 1910, pp. 229-41. 

22. Smith, P. A.: "Sex-Education in Japan." J. Ed. Psych., 1912, 
pp. 257-S3. 

23. Smith, Nellie M.: The Three Gifts of Life. 1913, pp. 138. 

24. Zenner, P.: Education in Sexual Physiology and Hygiene; A 
Physicians Message. Cincinnati, 1910, pp. 126. 



CHAPTER XVn 

THE TEACHER'S HEALTH 1 

The teacher's health is an important though neg- 
lected aspect of school hygiene. If the teacher is tuber- 
culous the children are directly exposed to contagion 
at a very susceptible period of life. If she is neuras- 
thenic, nervously unstable, querulous, or discontented, 
the effects upon the suggestible, sensitive child may 
be still more unfortunate. The welfare of children is 
so deeply involved that it is no longer justifiable to 
make the profession a haven for those of delicate con- 
stitution. 

There is little reliable information about the health 
conditions among our half-million teachers. We do 
not know definitely their mortality rates from vari- 
ous diseases, what class of material enters the pro- 
fession, to what extent health is injured by the work, 
or what measures would contribute to the conserva- 
tion of this most important body of public servants. 

Mortality rate and physical morbidity 

Balliett's health questionnaire, submitted to 159 
teachers, indicated that persons of average physical 

1 For a more extended discussion of this subject see The Teacher's 
Health, by Lewis M. Terman. Published by Houghton Mifflin Co., 
in The Riverside Educational Monographs, 1913, 136 pages. 



THE TEACHER'S HEALTH 271 

constitution suffer distinct impairment of health 
within five to ten years after entering the profession. 

Of five hundred New England and Middle West 
teachers questioned by Dr. Burnham, 37.4 per cent 
stated that their health had been injured in greater 
or less degree by the conditions of their work. The 
factors blamed were, in order of frequency, poor ven- 
tilation, bad lighting, nervous strain, standing, noises, 
overcrowded classes, chalk-dust, and too long periods 
of unbroken work. 

In Europe more extensive data are available. Sigel 
examined all the teachers of Leipzig, and found 42.8 
per cent definitely diseased. Karup's and Gollmer's 
statistics, from 12,381 German teachers, showed a low 
mortality rate from all causes combined, but a high 
susceptibility to tuberculosis and nervous diseases. 

Statistics from the National Provident Society of 
English Teachers, including 18,000 members, show a 
high morbidity rate from throat and chest troubles, 
influenza, nervous complaints, and gastro-intestinal 
disorders. Each year about 12 per cent of the entire 
number of teachers in this society receive sick bene- 
fits. Records of retirement under the English Super- 
annuation Act credit one third of the breakdowns to 
"neurasthenia," "nervous prostration," and "nervous 
debility." 

By virtue of an admirable Swedish law, granting 
sick allowances to teachers who have been ill one 
month or more, we have had, since 1906, complete 
morbidity records from all the 18,000 teachers of that 



272 HEALTH WORK IN THE SCHOOLS 

country. An average of 4 per cent of the male ele- 
mentary teachers and nearly 9 per cent of the female 
elementary teachers are out one month or more each 
year. The average period of disability is 4.9 months 
for the former and 5.6 months for the latter. Nervous 
troubles were responsible for 31.2 to 36 per cent of the 
illnesses, tuberculosis for 6 to 9.3 per cent, other re- 
spiratory troubles for 13.7 to 17.9 per cent, anaemia 
and general debility for 5.5 to 12.7 per cent, and in- 
testinal troubles for 7.6 to 8.9 per cent. We are also 
informed that 2.5 per cent of the active teaching staff 
of Sweden are sufferers from neurasthenia of "a pro- 
nounced type," and further that 1.17 per cent of the 
Swedish female teachers are tuberculous. 

If these figures hold for the United States our neu- 
rasthenic teachers would number about 12,500, and 
our tuberculous teachers about 5000. The former are 
teaching a full half-million children, the latter some 
two hundred thousand. 

Premature superannuation 

Teachers become prematurely superannuated. After 
the age of 45 or 50, new positions are not easily ob- 
tained. At an age when the lawyer, physician, min- 
ister, or man of affairs is at his zenith, the teacher is 
looked upon as passee. English teachers are retired 
on pension at an average of 53 years for males and 51 
for females. The average age for superannuation of 
male teachers is 49.1 years in Saxony, and 51.7 in 
Hesse and Bayern. 



THE TEACHER'S HEALTH 273 

Tuberculosis among teachers 

The mortality of teachers from tuberculosis is 
especially high. In Saxony this is 60 per cent higher 
for the years 20 to 29 than for the general male popu- 
lation, and 23 per cent higher between 30 and 39. 
In the Netherlands for the ages 25 to 35 the rate is 
60 per cent higher than for lawyers, and 30 per cent 
higher than for physicians. For Switzerland it is 
10 per cent higher than for the general population 
between 20 and 39 years, and 30 per cent higher be- 
tween 40 and 49 years. From a careful study of the 
prevalence of tuberculosis among the 3187 teachers of 
Paris, it was estimated that about 3 per cent of the 
French teachers in service are tuberculous. 

In Ontario, 57 per cent of the deaths among female 
teachers and about 30 per cent among male teachers 
are caused by tuberculosis. The corresponding figures 
for stone-cutters are 65 per cent, for lawyers, 25 per 
cent, and for farmers, 16 per cent. Official returns 
from the United States Census Bureau show that for 
ten of our large cities, averaged together, 39.6 per 
cent of the deaths among female teachers are caused 
by tuberculosis, 39.1 per cent among stone-cutters, 
26.8 per cent among saloon-keepers, and 13.9 per 
cent among farmers. For the entire census registra- 
tion area of the United States the following facts 
hold with great constancy and uniformity: (1) That 
for both male and female teachers the mortality rate 
from tuberculosis ranges from 19 to 26 per cent above 



274 HEALTH WORK IN THE SCHOOLS 

that for persons of the corresponding sex in other 
occupations; and (2) that for female teachers the 
rate is from 39 to 43 per cent higher than for male 
teachers. 

Mortality rates, after all, do not tell the whole 
story. Teachers belong to a highly selected class, both 
physically and morally, and ought to show a relatively 
low mortality rate. They also suffer from many 
minor complaints which do not greatly affect longev- 
ity, but which are destructive to efficiency and to the 
joy of living. 

The teacher as neurasthenic 

Few teachers of ten years' experience have escaped 
a nervous breakdown. Probably from 3 to 5 per cent 
of all our teachers are definitely neurasthenic. All 
the studies emphasize the exhausting nature of the 
teacher's work. Of the 305 German teachers reply- 
ing to Wichmann's questionnaire, 78 per cent suf- 
fered nervous troubles, the leading symptoms being 
morbid anxiety, 45 per cent; fixed ideas, 35 per cent; 
headaches, 71 per cent; heart palpitations, 58 per cent. 
These, however, are not average conditions, since 
the questionnaire no doubt elicited a disproportionate 
number of replies from those who were ill. 

The teacher's short day is more apparent than real. 
The conscientious teacher usually begins her duties 
nearly an hour before the class is assembled, and re- 
mains at the post until long after the close of the after- 
noon session. The teacher who can manage to limit 



THE TEACHER'S HEALTH 275 

her school day to less than seven hours, exclusive of 
evening work, may consider herself fortunate. In 
most cases evening lessons will consume one or two 
hours additional. Many teachers work nine or ten 
hours a day. 

The teacher's work cannot be adequately measured 
in terms of hours and minutes. She must work al- 
ways under full steam. An hour of teaching is prob- 
ably equivalent, from the standpoint of fatigue, to 
two hours of ordinary study, done in quiet without the 
necessity of speaking. Four hours of actual teaching 
thus represent about eight hours of ordinary office 
work. Add to this two hours for correcting papers, 
preparing lesson plans, supervising plays, etc., and the 
four-hour day has grown to one of ten. 

When teachers are overworked they must resort 
to the friendly protection of mechanical methods. 
Teachers who are sweated cannot do creative think- 
ing. Overworked teachers degenerate to the plane 
of lesson-setting and lesson-hearing. 

Emotional strain is added to intellectual overpres- 
sure. Many a teacher is constantly haunted by a vague 
fear of unpleasant conflicts with parents, pupils, or 
the school authorities. Most trying of all is the neces- 
sity of working under a school administrative regime 
which hedges the teacher about with unnatural re- 
straints and destroys her individuality. 

Other factors are overwork in the normal school, 
overcrowded classes, and the presence of exceptional 
children in the regular classes. Pupils who are incor- 



276 HEALTH WOEK IN THE SCHOOLS 

rigible or backward contribute more than their share 
to the worries of the conscientious teacher. 

The investigations prove that it is the beginning 
teacher who runs the greatest risk of pathological 
nervous exhaustion. With 47 per cent of Wichmann's 
neurasthenics the nervous troubles appeared in less 
than five years, and within fifteen years for 87 per 
cent. The reason is probably threefold: (1) the new 
teacher is more prodigal of energy from excess of en- 
thusiasm and because she has not learned the neces- 
sity of mental economy; (2) she lacks the experience 
which would enable her to work with the least ex- 
penditure of effort; and (3) the early years act as a 
sieve to eliminate all but the strongest. Whatever the 
relative shares of these factors, it should be under- 
stood that the first years of employment are critical 
for the teacher's health. To ignore the laws of physi- 
cal or mental hygiene at this period is to sow the seeds 
of lifelong nervous affliction and premature super- 
annuation. School administrators can aid in averting 
this danger by lightening the burdens of the young 
teacher, by instructing her in economical methods of 
work, and still more by patient sympathy, kindly 
criticism, and frequent encouragement. 

Salaries and tenure should be improved. The aver- 
age salary of the American teacher is about $450. It 
takes $800 for a small family to live in any of our 
larger cities in the style of a common laborer. Teachers' 
incomes are as little conducive to physical efficiency 
as to soul expansion. When teachers have worn them- 



THE TEACHER'S HEALTH 277 

selves out or become ill in the public service, they 
should not be turned out to subsist upon the charity 
of friends, but should be granted retiring allowances. 

Health suggestions for the teacher 

The teacher should learn the value of the "factor 
of safety" in mental economy. She is always in danger 
of short-sighted prodigality of energy. To live up to 
the last foot-pound of nervous energy daily is to fall 
into nervous bankruptcy at the first emergency. The 
teacher should find the safe limits for her day's work, 
and abide well within them. Sleepiness and the feeling 
of fatigue are the twin guardians of the "factor of 
safety." If their warnings are not heeded, insomnia, 
worry, and nightmares are pretty sure to follow. 

The eyes are the "weak link" in the health of many 
a teacher. Probably from 10 to 20 per cent suffer 
from unrelieved but relievable eye-strain. For the 
teacher to carry on "correspondence courses" with 
her pupils is to invite disaster. To face a light for 
several hours a day, as many teachers do, is alone 
sufficient to break down a good nervous system. When 
the eyes "go bad" the best oculist in reach should be 
consulted. 

If the teacher would be healthy, she should take 
varied daily exercise, preferably of the play type. 
Hobbies such as nature-study, horseback riding, 
tennis, golf, etc., are to be commended. Collateral 
work of sedentary nature is to be avoided. 

Vacation should be employed in such a way as to 



278 HEALTH WORK IN THE SCHOOLS 

rid the teacher's brain and muscles of the accumu- 
lated clinkers of a school year. If she belongs to the 
well-known variety pedagogia ancemia, she should 
carry to her schoolroom in September many millions 
more red corpuscles than she could have boasted on 
the previous commencement day. For the teacher 
to spend her entire vacation in professional study is 
intellectual as well as physical suicide. The vacation 
is preeminently a time for striking a new balance. 

No one has more reason than the teacher to know 
something of dietaries and food-values. Constipa- 
tion and indigestion drag innumerable teachers along 
the retrograde path to professional incapacity and 
premature superannuation. Habits of living and eat- 
ing which produce costiveness should be blacklisted. 
The deadly cold lunch, eaten in solemn silence, should 
be forsworn. Thanks to the thermos lunch-bottle and 
basket, the cold lunch is no longer a necessary evil. 

The pedagogical voice is expected to be anything 
but pleasant. "Teachers' nodes" are more common 
than "clergyman's sore throat." The teacher has 
five "voice days" per week, the clergyman but one. 
The teacher should therefore guard her voice as some- 
thing more than an instrument of communication. 
Success or failure may hang upon its quality. There 
is the voice which irritates and provokes, and another 
which inspires quiet and instills respect. In short, the 
teacher's voice is more important than her grammar. 
She can preserve it and improve it by learning how 
to use it and when to remain silent. 



THE TEACHER'S HEALTH 279 

The hygiene of character 

The teacher's work is likely to have certain reactive 
influences upon her character. The social instincts 
tend to atrophy. Teachers traditionally are bookish 
and unpractical, out of touch with civic and political 
affairs. Living an individualistic existence, they are 
always in danger of developing provincialism of in- 
tellect and character. The teacher should associate 
with people outside of her profession, and should keep 
one foot in the living, throbbing world. 

The social instincts of the teacher are also subject 
to perversions. We refer here particularly to male 
teachers, who so often are characterized by effemi- 
nancy, extreme docility, obsequiousness, and lack of 
manly force. Not a few superintendents and princi- 
pals become dictatorial, overbearing, and tyrannical 
toward their inferiors. 

The classroom teacher, also, may become dogmatic, 
exacting, and meddlesome in her relations to the chil- 
dren. Looking always after their faults and mis- 
takes, she tends to lose sympathy and generosity. 
She develops into a "Citizen Fixit. " Her rules be- 
come categorical imperatives. She forgets the value 
of the personal touch, fails to utilize the leverage of 
the child's natural instincts of suggestibility, loyalty, 
and hero-worship, and becomes prosy, prodding, and 
vexatious. 

Other dangers are method-cult, pedantry, and the 
didactic habit. Verbalism, rules, definitions, and pre- 



280 HEALTH WORK IN THE SCHOOLS 

ciseness of form tend to replace substance. The "rit- 
uals," called parsing, and the petty exactitude some- 
times required in the formal statement of arithmetical 
solutions, are good illustrations. Every slightly dif- 
ferent way of doing a thing comes to be labeled with 
a name of its own. Teachers are prone to overesti- 
mate the value of what they teach, some of which is 
obsolete fact, misapplied half-truth, or useless pedan- 
try. 

The result of all this is likely to be premature mental 
decay. The constant contact with little minds may 
dwarf the teacher's own mental growth. By dint of 
so many times doing the same thing in the same way 
she falls a "victim to fixed modes of interpretation." 
It is hard to be spontaneous, fresh, and inspiring at 
the hundredth repetition. New categories become 
less and less possible. The personality becomes " shut 
in. " When this state supervenes, intellectual progress 
comes to an end; firm, rigid lines settle in upon the 
soul — it is habit-bound. 

How to prevent mental fixation 

An important antidote is to reserve certain hours 
each day for a vacation from professional habits. This 
is recreation, which therefore should become the 
teacher's religion. It should involve play, the very es- 
sence of which is its creativeness and the relaxation 
from habitual routine, and it should be seasoned with 
constructive mental activity in some field of art, lit- 
erature, science, etc. This will foster the attitude of 



THE TEACHER'S HEALTH 281 

the learner, without which early decay is certain. The 
daily recreation will need also to be reinforced by va- 
cations spent in travel or in non-professional study. 

The teacher should cultivate the faculty of "doing 
the usual thing in the unusual way." The artist tem- 
perament should be her ideal, for the true artist abhors 
exact duplications and always endeavors to transvalu- 
ate all his experience. In every possible way variety 
should be mingled with the day's routine. Within cer- 
tain limits the teacher might be shifted from one grade 
or one department to another, or, where this is not 
feasible, a new position should be sought occasionally. 
To escape the danger of a premature mental arrest, 
every possible source of life and enthusiasm should be 
utilized. 

The responsibility of the normal school 

As regards the first of these points, there is reason to 
believe that the intense strain of the normal course 
directly contributes to the human wreckage which lit- 
ters the profession. Hardly any one will deny that 
normal-school students are as a rule overworked, but 
the overpressure is frequently justified on the plea of 
necessity. We may ask, however, whether it would not 
be wiser to lengthen the course a little instead of defy- 
ing the laws of nature in the effort to crowd three years 
of work into two, or four into three. 

In the second place, normal schools could contribute 
to the hygiene of the profession, and at the same time 
to the protection of the public, if they would conscien- 



282 HEALTH WORK IN THE SCHOOLS 

tiously undertake a selection in the admission of their 
students. Before entering upon the training course all 
candidates should be required to undergo a thorough 
physical examination made by experts employed by 
the school itself, — the physically unfit to be rejected. 
The examination should be repeated each year after 
entrance, and again when the candidate enters upon 
regular employment. In most other countries such 
examinations are given as a matter of course. 

In the third place, in order that teachers may be 
placed in a position to protect themselves from those 
risks to health and happiness which are sure to be 
encountered in the practice of their calling, as well as 
also for the sake of fitting them to act as the health 
guardians of their pupils, the subject of school hygiene 
should be raised from its present neglect and given the 
right of way in the normal-school curriculum. Instruc- 
tion in the subject should escape its present absurd 
limitation to the traditional (and sometimes obsolete) 
laws of heating, lighting, and ventilation, and ground 
itself upon the newer and infinitely broader conceptions 
of its bearing and scope. 

Finally, the normal school could contribute to the 
hygiene of the profession by conscientiously refusing to 
place its stamp of approval on candidates who are 
careless, ugly -tempered, cynical, and void of sympathy 
for children. The public is not in position to protect 
itself against poor teachers who have once been brev- 
etted with the school's diploma. We must stop the 
stream of undesirables at its source. 



THE TEACHER'S HEALTH 283 

Vocational guidance for teachers 

The normal school could also profitably engage in 
the work of vocational guidance of its students. Here 
the effort would need to go beyond the mere exclusion 
of the unfit, and include the direction of each candidate 
into that type and grade of teaching where her strong- 
est qualities would be most effective, and where her 
weakest would least imperil her success. 

Such work will have to be grounded upon a positive 
body of facts and principles, as yet largely unknown, 
relating to the psychology of teaching success. Its aim 
will be to distinguish fundamental traits of teacher- 
personality necessary for success in various lines of 
teaching. It will endeavor to place the teacher where 
she can do the most effective work; in the right grade, 
in the right subject, with the right sex, and in the most 
suitable environment generally. 

A by no means negligible product of any well-directed 
effort toward vocational guidance in the normal school 
will be the cultivation in the young teacher of a spirit 
of self-study and self-criticism, which throughout her 
career should point the way to self-improvement, to 
increased success, and to a wholesome spiritual attitude 
toward the inevitable vexations of the profession. 

REFERENCES » 

I. The Teacher's Physical Health 

*1. Burnham, W. H. : " A Contribution to the Hygiene of Teaching. 
Ped. Sem., 1904, pp. 488-97. 

1 For a complete bibliography see book by the writer, The Teach- 
er's Health. 1913, pp. 136. Boston: Houghton Mifflin Co. 



284 HEALTH WORK IN THE SCHOOLS 

*2. Hoag, E. B.: The Health Index of Children. (Chapter xi, pp. 
136-52.) 

3. Hulbert, H. L. P.: "The Care of the Teacher's Voice." Proc. 
Second Inter. Congress Sch. Hyg., 1907, pp. 862-66. 

4. Lowden, T. S.: "The Teacher's Health." Education, vol. xxix, 
pp. 30/. and 153/. 

*5. Oldright, Dr. William: "The Schoolroom as a Factor in Tuber- 
culosis." Proc. Second Inter. Congress Sch. Hyg., 1907, pp. 686- 
92. 
6. Schmid-Monnard, Dr.: "Die Ueberbiirdung der Lehrer an 
hoheren Lehranstalten." Zt. f. Schulges., 1899, pp. 701-06. 
*7. Small, W. S.: "The Hygiene of Teaching." Proc. American 

School Hygiene Assoc, vol. i, pp. 142-52. 
8. Steenhoff, Dr. G.: "The State of Health of Teachers in the 
Infant and Elementary Schools of Sweden." Inter. Mag. School 
Hygiene. 1911, pp. 564-66. 
*9. Terman, Lewis M. : The Teacher's Health : A Study in the 
Hygiene of an Occupation. 1913, pp. 136. 
*10. Van Tussenbroek, Dr. Cathrine: "Hygiene des Lehrkorpers." 

Rept. First Cong. Sch. Hyg., 1904, vol. iv, pp. 323-62. 
*11. Wichmann, Dr. R.: "Zur Statistik der Nervositat bei Lehren." 
Zt.f. Schulges., 1903, pp. 626, 696, 776; 1904, pp. 304, 543, 713. 

12. Williamson, Dr. R. T.: "The Medical Examination of School- 
Teachers." (Chapter xvm in Kelynack's Medical Inspection of 
Schools, 1910; same article in the Proc. Third Inter. Cong. Sch. 
Hyg., 1910, pp. 351-58. 

II. The Teacher's Mental Health and the Hygiene of 
Character 

13. Adams, J.: "The Dullness of Schoolmasters." Ed. Foundations, 
1911, pp. 350-67. 

14. Benson, Arthur C: "The Personality of the Teacher." Ed. 
Rev., 1909, pp. 217-30. 

15. Burk, F. D.: The Withered Heart of Our Schools." Ed. Rev., 
December 1907. 

*16. Hall, G. S.: "Certain Degenerative Tendencies among Teach- 
ers." Ped. Sera., vol. xn, pp. 454-63. 

17. Hughes, Edwin Holt: "The Reaction of the Teaching Profes- 
sion." Educator-Journal, 1906, pp. 223-30. 

18. Terman, Lewis M.: "The Teacher Psychosis." Scribner's 
Mag., November, 1908, pp. 505-08 (published anonymously). 

*19. Zergiebel, M.: "Zur Psychologie des Lehrers." Zt. f. Ped. 
Psych., 1911, pp. 471-83. 



CHAPTER XVIII 

WHAT THE WORLD IS DOING FOR THE HEALTH OF 
SCHOOL CHILDREN 

The purpose of this chapter is to give a brief review 
of the progress of school health work in various coun- 
tries. It is hoped that it may convey at least a general 
impression of the breadth and profundity of a move- 
ment which with us, as elsewhere, has developed so 
suddenly that even intelligent people who happen to 
be uninformed of its scope and fundamental purposes 
are likely to conceive of it as only another airy decep- 
tion to add to the already long list of American school 
fads. 

England 

Medical inspection in England was not a growth, 
but rather a sudden national awakening to the fact of 
racial deterioration. As late as 1902 there was no ade- 
quate system of medical inspection anywhere in the 
country; now it is universal. 

England's interest in physical education and other 
problems of child hygiene received its first great im- 
pulse from the disclosures of the results of conscriptions 
during the Boer War. The fact that about half of the 
army volunteers had to be rejected for physical unfit- 
ness touched deeply the national pride of England, and 



286 HEALTH WORK IN THE SCHOOLS 

brought a keen realization of the dangers of national 
decay through the physical degeneracy of the people. 
Numerous investigations, both governmental and pri- 
vate, were soon launched for the purpose of ascertain- 
ing the extent of physical deterioration and of suggest- 
ing means for its amelioration. 

In 1907 an Education Act was adopted which pro- 
vided for a compulsory system of medical inspection 
in all the public elementary schools of England and 
Wales, a system probably unsurpassed in any other 
country. The aet became effective in January, 1908, 
and within a year nearly all the 307 educational dis- 
tricts of England and Wales had complied with it. 

The important provisions of this act are two in num- 
ber: (1) medical inspection is made compulsory, and (2) 
the duty of executing it is specifically imposed upon 
the education authority. It is provided, however, that 
the education authority may, if it sees fit, arrange to 
have the work carried on under its supervision by the 
public health machinery already in existence. Prac- 
tically it makes little difference which course is pur- 
sued, since it places the responsibility for the conduct 
of the work upon the education authority. 

As interpreted by the Central Board of Education, 
the aim of the English Education Act is not primarily 
the medical inspection of children, but their physical 
and mental improvement. The subject of school hy- 
giene is related in every possible way to the public 
health work, and is viewed as an integral factor in the 
health of the nation. Doctors, teachers, and nurses 



WHAT THE WORLD IS DOING 287 

work together in the closest cooperation. The aim is 
not merely to improve the health of the children who 
are weakly or ailing, but in the broadest sense to con- 
serve the health of all children by adapting and modi- 
fying the system of education so as to make it fit their 
needs and capacities. 

No other nation, unless it be Japan, has adopted a 
school medical service with a more rational conception 
of its true purpose. In her school medical clinics Eng- 
land has boldly undertaken the free medical treatment 
of her ailing children, heedless of the criticisms of the 
medical profession. Her school physicians are as a rule 
full-time officers, highly trained and well paid. 

The leading organ of school health in England is the 
Journal of School Hygiene, published since 1910. 

Germany 

Germany's first school doctor was appointed in 1883, 
at Frankfort-on-the-Main. By 1905, 100 cities had a 
total of 598 school doctors, and by 1908, the number 
had risen to over 400 cities and 1500 doctors. 

In Germany, medical inspection of schools has not 
become a national movement, each of the several states 
composing the empire acting upon its own initiative. 
Thus far only two states have a state-wide school med- 
ical service for town and country alike, but everywhere 
there is lively agitation looking toward an extension of 
the work to rural schools, secondary schools, and pri- 
vate schools of all grades. 

German school doctors are nearly always part-time 



288 HEALTH WORK IN THE SCHOOLS 

officials. Even those who are employed for full time 
may supplement their salaries with private practice. 
The pay of the whole-time doctors ranges from $1750 
to $2750, with pension rights. School nurses are not 
very commonly employed, and the effectiveness of the 
service suffers greatly in consequence. There are many 
dental, but few medical, clinics. The school doctor 
never undertakes to give treatment, and all suggestions 
in this line meet with vehement opposition on the part 
of the practicing physicians. As stated by Fiirst, " med- 
ical inspection in Germany has gone only a little way 
toward its real goal of medical supervision." In this 
respect Germany is, with certain exceptions, distinctly 
behind a number of other countries. 

The Wiesbaden plan of medical inspection, which 
has become the model for many German and American 
cities, deserves special mention. It provides essenti- 
ally as follows : — 

1. A superficial examination of all new entrants. 

2. Following this a thorough physical examination of new 
entrants takes place within six to eight weeks after the open- 
ing of school. The results of the examination are recorded 
for each child upon an individual "health schedule," a card 
which contains spaces for the entries of health data secured 
from all the examinations made during the entire school 
life of the child. If a child requires continuous medical super- 
vision, the doctor inserts the words "Medical control" at 
the top of his schedule. 

3. Reexaminations of the same nature occur in the sec- 
ond, fourth, sixth, and eighth years of school life. 

4. The school doctor visits each school at least once a 
month, and each classroom at least once each half-year. 

5. All cases of infectious disease coming to the notice of 



WHAT THE WORLD IS DOING 289 

the head-master must be reported at once to the school 
doctor, who calls and inspects the class to which the patient 
belongs. All suspects are sent home, and kept under ob- 
servation for a few days. Orders for school closure, disin- 
fection, etc., must be sent by the school doctor to the local 
sanitary authority. 

The German method of making the medical examin- 
ation is of special interest because of its thoroughness, 
and might well be recommended to American school 
doctors. As described by Dr. Fiirst, it takes place as 
follows : — 

A teacher assists the school doctor by writing on the 
health schedules at his dictation. The children, who have 
been previously weighed and measured, approach the doctor 
in turn, stripped to the waist (including the younger girls). 
Their general condition is noted, then the chest measure- 
ment taken; the neck is palpated, and glandular swellings, 
enlarged thyroid, etc., are noted. The mouth is inspected, 
and the condition of the teeth and tonsils, and the presence 
of adenoids noted. The nasal and aural openings are super- 
ficially inspected and, if suspicious appearances present 
themselves, a more thorough examination of these is made. 
The back is now inspected, particular attention being paid 
to the spine; then the head and hair are looked at. Where 
appearances of illness present themselves, or the child com- 
plains of pain, etc., a more thorough physical examination 
is made, cases which cannot be satisfactorily diagnosed in 
the presence of the more or less fidgety class being reserved 
for private examination after the others have been dis- 
missed. 

In other ways than by medical inspection Germany 
affords us admirable examples of what schools can do 
for the health of their children. Swimming instruction 
is often obligatory, and school shower-baths are be- 
coming extremely common. In case of serious spinal 



290 HEALTH WORK IN THE SCHOOLS 

curvature, physical exercises of a corrective nature are 
prescribed by the school doctor, and carried out under 
his direction. Half-holidays and school journeys are 
common. Over two hundred cities supply from one to 
three daily meals to all necessitous school children, 
municipal grants supplementing private benefactions 
for this purpose. In the matter of special schools for 
defectives, Germany leads the world. Up to 1908 such 
schools had been established in about two hunded 
German cities. The open-air recovery school, already 
noted, is only one of the many types of special schools 
in Germany. 

In the amount of productive research, the number 
and value of its manuals and texts, and in its high-class 
scientific journals, Germany has contributed far more 
to the cause of school hygiene than any other country. 
The following are some of the most prominent German 
periodicals devoted to school hygiene and related sub- 
jects : — 

Zeitschrift fiir Schulgesundheitspflege. Monthly. Founded 

1888. 
Internationales Archiv. filr Schulhygiene. Quarterly. Founded 

1905. 
Das Schulzimmer. Quarterly (1903-10). 
Eos. Quarterly. Founded 1905. 
Zeitschrift fiir Kriippelfiirsorge. Quarterly. 
Soziale Midizin und Hygiene. Monthly. 

France 

Medical inspection began in France as early as 1834, 
when a school doctor was appointed for each boys' 
school in Paris. The service was extended to girls' 



WHAT THE WORLD IS DOING 291 

schools in 1843. The first school doctors, however, re- 
ceived no salary, and did little real inspection. It was 
not until 1879, when Paris organized an extensive sys- 
tem, that medical inspection in France could really be 
said to have begun. From that date the movement 
spread rapidly to other cities. By the Education Act of 
1886 the legal position of medical inspectors was fully 
established, and at present practically all the cities 
have a system based more or less intimately on that of 
Paris. 

For many years the work in France was confined 
almost entirely to sanitation and the prevention of 
contagious diseases. Only a few cities — such as Nice, 
for example — have undertaken the careful individual 
examination of all of their school children, though the 
attention of French school doctors is rapidly turning 
to the fundamental problems of child hygiene. 

Other notable activities conducted by French edu- 
cational authorities are school feeding and "vacation 
colonies." The latter have recently become extremely 
popular, so that it is not at all rare for the wealthier 
communes (districts, or wards) of cities to purchase 
large estates in the country for the special use of vaca- 
tion colonies for school children. In choosing the pu- 
pils for such excursions preference is given to children 
who are anaemic, feeble, convalescent from acute illness 
or pre-tuberculous. Some districts maintain resorts 
both at the seaside and in the country, the school doc- 
tor deciding which place would be of the greatest ad- 
vantage to a given child. 



292 HEALTH WORK IN THE SCHOOLS 

Mention should be made of the French League of 
School Hygiene, and also of the Society of Medical 
Inspectors of Paris and the Seine. Both are active 
associations, the former publishing the quarterly jour- 
nal entitled L'Hygiene Scolaire, and the latter the 
monthly organ La Medecine Scolaire. 

Switzerland 

All but a few of the cantons of Switzerland have a 
well-matured system of medical supervision for the 
cities, and some of them have extended the work into 
rural schools as well. The duties of the school doctor 
usually include the complete sanitary supervision of 
the school buildings and grounds, and the examina- 
tion of children for all kinds of defects, debility, and 
mental deficiency. Both Zurich and Geneva have re- 
markably efficient school medical service. Lucerne 
has instituted school medical and dental clinics. The 
latter registered 3443 attendances in 1908-09. 

Owing to the high level of intelligence and education 
among the people of Switzerland the advice of school 
physicians is almost invariably acted upon, and an 
elaborate follow-up service is unnecessary. The Swiss 
Society for School Hygiene, which enrolls over seven 
hundred active members, has done effective work in 
promoting medical inspection, and publishes, besides a 
Year-Book, The Swiss Journal of School Hygiene and 
Child Protection. 



WHAT THE WORLD IS DOING 293 

Sweden 

In the medical inspection of schools Sweden has long 
been a pioneer. As early as 1868 all the public secon- 
dary schools in the kingdom had medical officers on 
their staffs. The present code for secondary schools, 
which dates from 1905, provides for the appointment 
and remuneration by the Government of at least one 
medical officer for each school. 1 

The method of examination is almost exactly iden- 
tical with that provided for by the celebrated Wies- 
baden plan, and so need not be described in detail. 2 The 
duties of the school physician are, however, of decidedly 
broader scope than in most other countries, in that 
they include an administrative as well as an advisory 
function. The school physician is expected to super- 
vise the construction of new buildings; to see that the 
sanitary arrangements are satisfactory; to draw up a 
plan of procedure for janitors and other employees, and 
to see that it is carried out; to exercise constant over- 
sight of the methods of physical education; and finally 
even to supervise the instruction given in the several 
branches of the curriculum. We have in this a sugges- 
tion of the rapidly broadening scope of educational 
hygiene. 

For the public elementary schools Sweden has not 
yet established a general system of medical inspection. 

1 It should be noted that Swedish secondary schools correspond 
to those of Germany, and not to those of the United States. 

2 See p. 288. 



294 HEALTH WORK IN THE SCHOOLS 

However, all of the larger cities and some rural com- 
munities support, on their own initiative, a school 
medical service similar to that supplied by the Govern- 
ment to secondary schools. Foremost of the Swedish 
cities in this respect is Stockholm, which maintains a 
system of examinations similar to those of Wiesbaden 
and Paris, and in addition has set the notable example 
of voting public funds for carrying on research in school 
hygiene. In 1906, the city granted to Dr. C. Siindell 
the sum of $495 for the investigation of schoolroom 
air, in relation to heating and ventilation; $280 to Dr. 
J. Hanmar, for the study of fatigue, as influenced by 
various forms of school work; and $55 for an inquiry 
into the influence of vertical and slant writing upon 
sitting posture. The budget for 1907 included appro- 
priations amounting to $1375 for investigations relat- 
ing to school hygiene. Of this, the sum of $440 was 
allotted to Dr. Siindell for the study of delicate and 
anaemic school children, and of the home conditions 
under which they live; to Dr. Hanmar an equal amount 
for the continuation of his study of school fatigue; and 
to Dr. K. Soderling about $500 for the double purpose 
of investigating the possibilities of natural lighting of 
schoolrooms (a difficult problem for a part of the 
school year in Sweden, owing to the high northern lati- 
tude), and the most suitable sizes of children's school 
desks. The same amount ($1375) was appropriated for 
investigations in 1910. 

If the educational authorities in all parts of the 
world were simultaneously to emulate this example by 



WHAT THE WORLD IS DOING 295 

undertaking similar investigations, many important 
and challenging problems of school hygiene would soon 
be brought to solution. 

In regard to dental clinics, medical dispensaries, 
school feeding, and the care of tuberculous children, 
Swedish schools are on the whole abreast of the most 
advanced practices in other countries. Medical treat- 
ment is provided in many polyclinics and in at least six 
cities by free dental service. 

Denmark 

There is no general school medical service in Den- 
mark, and such inspection as has been carried on has 
been directed mainly toward the control of infectious 
diseases. However, Copenhagen, Frederiksberg, and 
a few of the larger provincial towns have undertaken 
medical inspection on their own initiative, adopting 
in most cases the Wiesbaden system. Copenhagen has 
one part-time physician for 2000 to 4000 children, 
while Frederiksberg, with its 8000 school children, 
employs one for full time. The Tuberculosis Act of 
1905 has led to an excellent and uniform method of 
janitor service for all state-managed schools. 

Norway 

Since the Education Act of 1896, Norway has re- 
quired medical inspection of all its public secondary 
schools. Since 1889 there has been a permissive law 
for public elementary schools, in towns which are will- 
ing to meet the expense. Most towns now have such 



296 HEALTH WORK IN THE SCHOOLS 

inspection. As a result of the Tuberculosis Act of 1901, 
special attention is now given to children who appear 
anaemic or otherwise debilitated. 

Scotland 

In 1902, while the Boer War was in progress and the 
British nation was effectively roused to questions of 
physical degeneracy, King Edward VII appointed a 
committee of nine to inquire into the state of physical 
training in the schools of Scotland. The committee 
was composed of some of Scotland's most eminent 
statesmen and physicians. There resulted in 1908 the 
Education Act of Scotland, which conferred upon the 
971 school boards the powers necessary for a complete 
system of medical inspection. While this act is nomin- 
ally not mandatory, it is so in effect. Practically all 
schools, whether primary, secondary, or technical, 
including continuation schools, must either provide 
for medical inspection or give facilities to the school 
board. Even private schools may provide medical 
inspection at public expense. The counties, as a rule, 
provide the same excellent system as do the large 
cities. 

As in England, the child hygiene movement in Scot- 
land has progressed with almost incredible rapidity. 
According to a recent provision, all candidates for the 
teaching profession are required to take a course of 
training in school and personal hygiene embracing not 
less than seventy hours. For this purpose seven full- 
time and two part-time physicians are employed as 



WHAT THE WORLD IS DOING 297 

lecturers by the four training schools for teachers. 
The same physicians also medically examine all stu- 
dents in training, both at the beginning and the end of 
their course. The College of Hygiene and Physical 
Training, founded by the Carnegie Dunfermline Trust, 
provides highly qualified special teachers of hygiene. 
Glasgow and Edinburgh support special schools for 
physically and mentally defective children, but thus 
far there are few open-air schools in Scotland. One of 
the most important of all statistical documents yet 
published, for the study of the sociology of the school 
child, is the Report, by Dr. W. Leslie Mackenzie and 
Dr. A. Foster, on The Physical Condition of Children 
attending the Public Schools of Glasgow. The cause of 
child hygiene in Scotland owes an incalculable debt of 
gratitude to the pioneer efforts of Dr. Mackenzie. 

Ireland 

In matters of school hygiene Ireland affords the 
most shocking conditions to be found in any country 
which lays claim to civilization. The facts as presented 
by the most responsible writers and observers sound 
incredible. 

A majority of the buildings are deplorable struc- 
tures, extremely small, low, thatched but not ceiled, 
"old, decayed, rat infested, base, and unsightly hov- 
els." Many are filthy, squalid, damp, miserably 
lighted, and absolutely without ventilation. Sometimes 
as many as 80 children are crowded into a room 13 X23 
feet, and retained there from 10 until 2 o'clock without 



298 HEALTH WORK IN THE SCHOOLS 

intermission. The atmosphere becomes pestilential 
and sickening. The seats are universally crude and ill- 
fitting. One eighth of the elementary schools of Ireland 
are without toilet conveniences of any kind. There is 
often no janitor work beyond what teacher and pupils 
do voluntarily, nor in many schools is there any provi- 
sion for heating. One third of the schools of Belfast 
have no playgrounds whatever. 

The inevitable results of this neglect appear on 
every hand. The mortality of school children is higher 
than for the population generally. Epidemics of mea- 
sles, scarlet fever, whooping-cough, etc., are frequent. 
Between the ages of 10 and 15 years the death rate 
from tuberculosis is appalling, while the relative health- 
fulness of the children below school age points unequi- 
vocally to the cause. 

Canada 

Ontario passed a permissive act in 1909 and medical 
service has been inaugurated in Hamilton and Brant- 
ford. Manitoba passed a similar act in the same year, 
and Winnipeg at once availed itself of the legislation. 
The Province of British Columbia adopted, in 1910, a 
thoroughgoing medical service for all the city and rural 
schools. 

The city of Montreal has had school medical service 
since 1906. Interest in the question was first aroused 
by the Montreal Women's Club, which in 1902 began a 
campaign of education looking toward this end. After 
four years of agitation their efforts were successful. 



WHAT THE WORLD IS DOING 299 

The emphasis is primarily on the prevention of con- 
tagious disease and the improvement of sanitation, 
though the work has incidentally had other favorable 
results. 

Australia 

Medical inspection of some kind has been under- 
taken in most of the Australian provinces. New South 
Wales has taken up the work in a particularly compre- 
hensive way, laying stress upon the cooperation of 
teachers. 

The results of medical inspection in a country like 
Australia have special interest, for the reason that they 
may be expected to afford an index of the influence 
upon children's health of exceptionally favorable eco- 
nomic and climatic conditions. Thus far the results 
are no less disturbing than the disclosures brought 
about by medical inspection in other countries. 

Japan 

The Japanese, who never do educational things by 
halves, have one of the most thoroughgoing systems to 
be found in the world. They rightly regard the school 
child as the nation's most valuable asset, and consider 
it a matter of national expediency as well as duty to 
explore the extent and quality of this resource. Ac- 
cordingly most of the public schools have been annu- 
ally inspected by salaried school physicians since 1898. 
Annual records are made of height, weight, chest cir- 
cumference, nutrition, and all forms of defectiveness. 



300 HEALTH WORK IN THE SCHOOLS 

The resulting statistics are among the most complete 
and valuable ever collected. 

Other countries 

Thus we see that most of the civilized countries of 
the world have some system or other of school medical 
supervision. Among others not previously mentioned 
are Hungary, Austria, Belgium, Holland, Roumania, 
Bulgaria, Chile, Argentine Republic, South Africa, and 
even individual cities in such semi-benighted countries 
as Russia and Egypt. 

The United States 

Medical inspection of schools in the United States is 
of very recent growth. Beginning in Boston in 1894, it 
was taken up by Chicago in 1895, by New York, in 
1897, and by Philadelphia in 1898. At least 90 cities 
had medical inspection in 1907, 337 in 1910, and prob- 
ably not far from 500 in 1913. This includes practi- 
cally all of the larger cities and many of the smaller. 
In 1910 the cities of the country employed 1194 school 
doctors and 371 nurses, while 48 employed school 
dentists. 

By May, 1911, nineteen States had passed laws pro- 
viding for the medical inspection of schools. In nine 
States the laws are mandatory. A few States have since 
begun the establishment of State Departments of 
Child Hygiene. 

Attention may be called to the following salient facts 
regarding medical inspection of schools in the United 



WHAT THE WORLD IS DOING 301 

States: (1) The control is usually vested in the board 
of education, instead of the public health author- 
ities; (2) of the 301 cities supporting a school med- 
ical service, nearly half confine their work to the 
detection and control of contagious disease; (3) only 
one State (New Jersey) has a mandatory provision 
requiring treatment for defects discovered; (4) tests of 
vision and hearing are usually made by the teachers; 
(5) the movement is growing with greater momentum 
each year; (6) the office of school physician is still 
wretchedly underpaid. 

Only sporadic attempts have yet been made in the 
United States to introduce school feeding or school 
dentistry. Open-air schools are becoming extremely 
popular, the number increasing enormously each year. 
In the way of special schools for defectives we cannot 
yet match the admirable system of auxiliary schools in 
Germany, but the movement is being vigorously 
pushed. 

The American Association of School Hygiene was 
organized in 1907, and has published four volumes of 
Proceedings. Unfortunately we have no journal de- 
voted to school hygiene. It is hoped that the fourth 
meeting of the International Congress of School 
Hygiene, which occurred at Buffalo in 1913, will result 
in increased momentum to our school health reform. 

Conclusion 

It is surely evident, even from this brief account, 
that the medical inspection of schools is a movement 



302 HEALTH WORK IN THE SCHOOLS 

of great portent. A little time hence we shall doubt- 
less look back upon the marvelous development of 
intellectual education of the nineteenth century, and 
its simultaneous neglect of the body, as one of the 
strange paradoxes of educational history. 

Attention, however, should be called to the fact that 
in most countries the medical service for secondary 
schools has been made a matter of slight consideration. 
It is right that those schools which contain the masses 
of the nation's children should be provided for first, 
but similar action should follow for all other types of 
schools. The old assumption that because children 
attending the higher schools are usually from a better 
class of homes, they must therefore be practically free 
from defect, has been entirely disproved. If it be true, 
as seems probable, that the secondary schools enroll, 
on an average, pupils of somewhat more than ordinary 
native endowment, then so much the more important 
for them are the things which concern health. 

REFERENCES 

*1. Ayres, Leonard P.: Medical Inspection Legislation. Bulletin 
no. 99, Russell Sage Foundation, Dept. Child Hygiene, 1511. 

*2 Ayres, Leonard P.: "What American Cities are doing for the 
Health of School Children." The Public Health Movement, 
1911, pp. 250-60. Published by the American Academy of 
Political and Social Science. 

3. Burnham, William H.: "Health Inspection in the Schools." 
Ped. Sem., 1900. 

4. Crowley, Dr. R. H.: The Hygiene of School Life. 1909. 

5. Dufestel, Dr. L.: Guide Pratique de MSdicin Inspecteur des 
ftcoles. Paris, 1910. 

6. Franke, Kurt: " Schulhygiene in Japan." Zt.f.Schulges., 1912, 
pp. 729-39. 

*7. Gulick and Ayres: The Medical Inspection of Schools. 1913. 



WHAT THE WORLD IS DOING 303 

*8. Hogarth, A. H.: The Medical Inspection of Schools, 1909. 

(Chapter n, "History and Legislation.") 
*9. Kelynack, T. N.: The Medical Inspection of Schools and 

Scholars. 1910, pp. 434. (Best summary on medical inspection 

progress.) 
"10. Shafer, George H. : " Health Inspection of Schools in the United 

States." Ped. Sent., 1911, pp. 273-314. 

11. Scot, Vere: "The Blight on Irish Schools." School Hygiene, 
1912, pp. 230-33. 

12. Terman, Lewis M.: "Medical Inspection of Schools in Cali- 
fornia." Psych. Clinic, March, 1911. 

*13. Terman, Lewis M.: The Hygiene of the School Child. 1913. 

14. Terman, Lewis M.: The Teacher's Health. 1913. 

15. See the Proceedings of the International Congresses of School 
Hygiene, 1904, 1907, 1910, and 1913; also the Annual Reports 
of the American Congresses of School Hygiene, from 1907; the 
most important journals of school hygiene, such as Zeitsckrift 
fur Schulges; Inter. Mag. of Sch. Hyg., and the (English) 
Journal of School Hygiene. 



APPENDIX 

SCHOOL HEALTH ORGANIZATION IN VARIOUS 
CITIES OF THE UNITED STATES 

Milwaukee 

The Milwaukee School Health Department is maintained 
by the Board of Education, and has (1913) the following 
organization : — 

One medical director. 

Ten assistant medical inspectors. 

One specialist on diseases of the eye, ear, nose, and throat. 

One full-time dental inspector. 

One special assistant for psychological and anthropologi- 
cal tests. 

Five school nurses. 

The medical director, dental inspector, and nurses, devote 
their entire time to their work; the remainder of the staff 
give one half of each day. A central office is maintained 
where the medical director meets parents, conducts special 
examinations, and carries on the general office work of the 
department. A dental clinic for indigent children, an out- 
door school, and a school for crippled children, have re- 
cently been added. There are four classes for blind children, 
and four centers for the treatment of speech defects. 

The city has been divided into ten geographical districts, 
nine of which are approximately equal in size and contain 
about the same number of schools; the tenth, located in the 
central, or slum, portion of the city, covers less area because 
the schools are closer together and the conditions met 
among the pupils worse than in the outlying sections of the 
city. Each district is under the care of one assistant medical 
inspector. For the work of the nurses, the city has been 
divided into five districts, the four outlying territories being 
about equal, and the fifth in the center of the city, being 
considerably smaller. 



306 APPENDIX 

Each school has been supplied with the following mate- 
rials: — 

1. A case for the filing of the doctor's and nurse's rec- 
ords. 

2. A circular for the principal, explaining in brief the 
purposes of medical inspection, his duties in its accomplish- 
ment, and information as to causes and time of exclusions. 

3. A circular for each teacher, detailing her duties, and 
giving information as to the early symptoms of contagious 
diseases. 

4. Code cards for all teachers on which all diseases of 
importance are indicated, by numbers. 

5. Blue cards, for requests from teachers for an immediate 
examination. 

6. Psychological examination blanks, with circular of 
explanation. 

7. Physical examination blanks. 

8. An emergency case, containing a stretcher, drugs, and 
dressings. 

Complete directions are given to the medical inspectors 
and nurses in respect to their routine work in the schools. 
Principals of schools are also instructed in respect to the 
general plan of health supervision. Indigent children, suf- 
fering from physical defects, are referred to the various 
city dispensaries. 

The general plan of examination is as follows: — 
A blue card constitutes the request of the teacher for an 
examination for one of her pupils, whom she suspects of be- 
ing afflicted with some acute condition requiring immediate 
care. When the class assembles in the morning, the teacher 
rapidly inspects her pupils, and if she finds anything abnor- 
mal in the appearance of a child she makes out this card. 
On this card she gives the name, address, school, grade, 
teacher, date, and reason for sending the child. When the 
doctor's signal is given, or a monitor informs her of the 
doctor's presence in the school, she gives the child selected 
for examination its blue card, and sends it to the room in 
which the doctor makes his examinations. The doctor ex- 
amines each child presented, makes his diagnosis, and on 
the stub attached informs the teacher of his findings, whether 
the child is to be excluded or not, and, if excluded, for how 



APPENDIX 307 

long. The card itself is placed on file, and the case followed 
up by nurse and doctor until cured, when the card is sent 
to the central office for tabulation. If the case is such that 
the doctor considers exclusion desirable, a yellow card is 
made out, giving the cause for exclusion, the date on which 
the child is to report for reexamination, and the date of re- 
examination and readmission. Attached to this card is a 
letter form which is sent home in a sealed envelope with 
the child, informing the parents of the exclusion and the 
cause. 

Each child in the schools receives also a physical examina- 
tion. The result of this examination is kept on a blank made 
out in duplicate, and so arranged as to provide for annual 
records for a period of nine school years. The information 
recorded on the blank comprises the name, birthplace, sex, 
age, school, grade, nationality of father and mother, history 
of measles, scarlet fever, diphtheria, pertussis, date of phy- 
sical examination, vaccinations, height, weight, nutrition, 
presence or absence of hypertrophied tonsils, adenoids, de- 
fective nasal breathing, defective palate, defective teeth, 
myopia, hypermetropia, other eye defect, defective hearing, 
deformities of the spine, trunk or extremities, tubercular 
lymph nodes, pulmonary, cardiac or nervous disease, chorea, 
epilepsy or stammering. One copy is sent to the central 
office and one copy is placed on file at the school, so that the 
principal and teacher may know the physical condition of 
each child in the school. When the child is placed under 
another teacher, either by promotion, demotion, or transfer 
to another school, the card is presented to this teacher, who 
is thereby informed concerning any defects which the new 
pupil may have. 

The Milwaukee system is as near ideal as any in the coun- 
try, and is thoroughly practical and efficient in organiza- 
tion and results obtained. Schools expecting to undertake 
complete health supervision of their pupils cannot do better 
than to study the Milwaukee system. 

Health Organization in the Minneapolis Schools 

This department is organized to include, so far as possi- 
ble, all matters pertaining directly to the health of the child. 



308 APPENDIX 

It therefore includes all the physical training activities, 
gymnastics, folk-dancing, athletics, both high and grade 
school, those playgrounds that are conducted by the board 
of education, whatever physical training work is done in 
the night schools, etc. 

The school for stammerers, special classes for children who 
are mentally retarded and deficient, open-air schools, the 
school gardens, and the truant schools are also all under the 
general supervision of the school health department. 

The official organization is as follows : — 

One medical director (on full time). 

Eight assistant medical officers (on half time). 

Eighteen school nurses (on full time). 

Twelve instructors in physical training (on full time). 

Eighteen playground instructors during the summer 
months. 

One supervising school nurse. 

The work of the Minneapolis School Health Department 
is maintained by the board of education, and is one of the 
most efficient departments now organized. It is interesting 
to note with what completeness the divisions of medical 
supervision and physical education are organized and re- 
lated in this city. 

Philadelphia 

Philadelphia, under the management of Dr. Walter 
Cornell, has recently reorganized its school health work as 
follows : — 

The examination of school children is conducted by the 
city health department, but the expense is borne by the 
board of education. Under ordinary conditions this plan 
could not be recommended, but at present it appears to 
work satisfactorily in Philadelphia. The school nurses are 
employed and paid by the board of education. 

The scope of the work at present includes : — 

1. Routine examination of every child once each year, as 
required by the state law. 

2. Sanitary inspection of school buildings. 

3. The detection and exclusion of children suffering from 
contagious diseases. 



APPENDIX 309 

4. The examination of absentee children, for the Bureau 
of Compulsory Education. 

5. Special examination of mentally deficient children. 

6. Medical supervision of open-air classes for anaemic and 
tubercular children. 

7. Examination of applicants for position of school janitor, 
and other positions in the department of buildings. 

8. Medical supervision of special classes for blind or 
crippled. 

9. The supervision of candies and other foodstuffs sold 
by vendors around the school premises is being projected, 
and will soon be put into effect. 

Oakland 

Oakland, California, has had since 1909 an excellent or- 
ganization under the direction of Dr. N. K. Foster. The 
plan is in some respects unique, and has given splendid results. 
It consists of the following : — 

One medical director. 

One assistant medical officer. 

Seven school nurses. 

Each nurse has her own particular schools in which to 
work. At the beginning of the year a special attempt is 
made to give attention first to those pupils who are urgently 
in need of it. This is accomplished through the efforts of 
the teachers and nurses. In this way the worst cases are 
detected and followed up early in the year, a point of much 
importance. After this preliminary work is finished, the 
nurse examines all of the pupils in her district, and sends 
notices of defects discovered to parents. Follow-up work 
is done in the case of each child whose parents receive a 
notice. 

An interesting and valuable part of the nurse's work con- 
sists in simple "health talks" to the individual pupils, at 
the time of the physical examination, particularly in rela- 
tion to the defects or disorders from which they suffer. 
Health talks are also given the entire classes both by the 
school nurses and school doctors, and special attention is 
given to instruction in matters pertaining to sex-hygiene. 

A central office is maintained by the board of education 



310 



APPENDIX 



at which the school physicians keep office hours, so that 
parents may come with their children for special examina- 
tions and consultations in respect to further action. 

The entire department is maintained by the board of 
education, and the plan works admirably in every respect. 



Health Organization in New York City Schools 

The medical supervision of school children in New York 
City is maintained under the division of child hygiene of 
the city board of health. The division of child hygiene was 
reorganized in 1912, and at present consists of the following 
plan : — 

Organization of the Division 









DIRECTOR. 










Assistant Director. 
Supervising Inspector 
Superintendent of Nur 


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ses. 




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Borough of 
Brooklyn 




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Borou 
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Boron 
Rich 


ghof 
nond 


Bon 

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Bore 
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Bor 

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Bore 
Ch 


ugh 
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Bore 

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ugh 
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Super 
Inspe 


vising 

:tors 




Super 
Inspe 


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Super 
Inspe 


vising 
ctors 




Super. 
Inspec 


rising 
tors 




Super 
Inspe 


vising 

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Super 
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vising 
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Super 

Nui 


vising 

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rising 
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sisfng 
ses 


Medi 
Inspe 


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ctors 




Medic 
Inspe 


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ctors 




Medi 
Inspe 


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ctors 




Medic 
Inspe 


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ctors 




Medi 
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ctors 


Nurses 




Nurses 




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Nurses 


Nurses* 
Assistants 




Nurses' 
Assistants 




Nurses' *- 
Assistants 




Nurses' 
Assistants 




Nurses* 
Assistants 



APPENDIX 311 

Borough Organization 

Borough chief, in each borough. (Directly responsible to the 
director, and in charge of the indicated borough.) 

Supervising inspectors. (Each in charge of a squad of 
from ten to fifteen inspectors and under the direct super- 
vision of the borough chief.) 

Supervising nurses. (Each in charge of a squad of from 
fifteen to twenty nurses, and directly responsible to the 
supervising inspectors.) 

Medical inspectors. 

Nurses. 

Nurses' assistants. 

Under the subdivision of school hygiene there are em- 
ployed, in addition to the supervising school medical officers 
and supervising school nurses, 74 medical inspectors and 
179 school nurses. The control of contagious diseases has 
been placed in the hands of the school nurses, while the 
medical officers in the schools devote their time to the work 
of making physical examinations. School nurses treat many 
of the eye and skin diseases discovered in the schools, while 
free dispensary treatment is provided for all other cases 
which cannot receive attention from family physicians and 
specialists. 

Present Procedure 
Objects: — 

1. The repeated and systematic inspection of all school 
children for the purpose of early recognition of conta- 
gious disease. 

2. Exclusion from school attendance of all children af- 
fected with an acute contagious disease. 

3. Subsequent control of the case with isolation of the 
patient, and disinfection of the living apartment after 
termination of the illness. 

4. Control and enforced treatment of contagious eye and 
skin diseases with the purpose of diminishing the num- 
ber of children excluded from school attendance. 

5. Knowledge of unreported cases of contagious disease 
among school children at home. 



312 APPENDIX 

6. Complete physical examination of each school child 
with reference to the existence of any untreated phys- 
ical abnormality. 

7. Education of the parents as to the necessity of ob- 
taining proper medical care for untreated physical 
defects. 

8. Provision for facilities for the treatment of contagious 
eye and skin diseases and non-contagious physical 
defects occurring in school children. 

The complete system of school medical inspection is 
carried on in 517 public schools with a registered attendance 
of 684,207 pupils. In addition, 151 other free schools of the 
city receive a more or less complete series of inspections for 
the purpose of detecting contagious diseases. Seventy-four 
medical inspectors and 179 nurses are detailed to the work 
of school medical inspection under the immediate super- 
vision of the staff of supervising inspectors and supervising 
nurses in each borough. Each inspector is assigned to duty 
in a group of schools with an average registration of nine 
thousand pupils. Each nurse is assigned to duty in a group 
of schools with an average registration of four thousand 
pupils. 

Each public school in the city is visited each day by a 
nurse, except in certain outlying and sparsely populated 
districts where visits are made at less frequent intervals. 
Other free schools are visited upon request, or regularly 
once or twice weekly. 

The school medical officers follow the routine indicated 
in the outline which is given below : — 

The diagnosis and correction of non-contagious untreated phys- 
ical defects: — 

1. The medical inspector visits each school under his 
jurisdiction for two successive days. A regular schedule 
is maintained, and the principals of the schools are 
thus informed of the dates of the inspector's visits. 
The principals are requested to instruct the children 
to report, in small squads, to the inspector for physical 
examination. 

2. Examinations are made in the following order: — 
(a) Children entering school for the first time. 



APPENDIX 313 

(b) Children especially referred by the principals or 
teachers. 

(c) Children belonging to the class to be graduated. 

(d) In the regular course, beginning with children of 
the lowest grades, and proceeding to the higher 
grades in regular order. 

(e) Classes of the same grade are examined in regular 
order in each school of the group. 

3. Each child is thoroughly examined for the following 
conditions : — 

Defective vision. 
Defective hearing. 
Defective nasal breathing. 
Hypertrophied tonsils. 
Tuberculous lymph nodes. 
Defective teeth. 
Malnutrition. 
Pulmonary disease. 
Cardiac disease. 
Chorea. 
Orthopaedic defects. 

4. A complete record of each physical examination is made 
on a special form. If a child is normal, the inspector 
sends such a report to the borough office of the divi- 
sion. If abnormalities are found, the record form is 
given to the school nurse. 

A duplicate record of each child's condition is also placed 
on file with the child's school record, thus affording to the 
educational authorities the fullest information in regard to 
the child's physical condition, and enabling them to take 
advantage of this information in adjusting the individual 
curriculum. 

The nature and results of the treatment obtained for each 
defect are thereafter noted upon this school record form by 
the nurse. 

The inspectors and nurses are required to cooperate to the 
fullest extent with the principals and teachers, giving to 
them all possible data in relation to the children found to be 
physically defective, and to offer suggestions in the way of 
school adjustments which may tend to correct the existing 
defects. 



314 APPENDIX 

The cities cited furnish practical information of what is 
actually being accomplished in some of the representative 
places of the United States, and will thus indicate to other 
cities of a similar size how organization may be successfully 
begun. 1 

1 For an intensive study of the methods and results of medical 
inspection in twenty-five representative cities of the United States, 
see Louis W. Rapeer: School Health Administration. 1913, pp. 360. 



SUGGESTIONS 

FOR A TEACHER'S PRIVATE LIBRARY IN 
SCHOOL HYGIENE 

A. General 

(A selected list of sixteen of the best books, which retail for a total 
of $30.25.) 

1. Allen, W. H.: Civics and Health. Ginn & Co., Boston, 

1909, pp. 411; price $1.50. 

2. Ayres, Leonard P.: Open-Air Schools. Doubleday, 
Page & Co., New York, 1910, pp. 165; price $1.00. 

3. Bryant, Louise Stevens: School Feeding. Lippincott 
Co., Philadelphia, 1913, pp. 345; price $1.50. 

4. Cornell, Walter S.: The Health and Medical In- 
spection of School Children. Davis Co., Philadelphia, 

1912, pp. 614; price $3.00. 

5. Crowley, Ralph H.: The Hygiene of School Life. 
Methuen & Co., London, Eng., 1910, pp. 393; price 
$1.50. 

6. Denison, Elsa: Helping School Children. Harper & 
Bros., New York, 1913, pp. 352; price $1.50. 

7. Dresslar, F. B. : School Hygiene. The Macmillan Co., 
New York, 1913, pp. 369; price $1.25. 

8. Gulick, Luther, and Ayres, L. P. : The Medical In- 
spection of Schools. Russell Sage Foundation, New York, 

1913, pp. 224; price $1.50. 

9. Hoag, E. B. : The Health Index of Children. Whitaker 
and Ray-Wiggin Co., San Francisco, 1910, pp. 188; 
price $.80. 

10. Hogarth, A. H.: The Medical Inspection of Schools. 
Oxford University Press, London, Eng., 1909, pp. 360; 
price $1.50. 

11. Kelynack, T. N: (editor) The Medical Examination 
of Schools and Scholars. P. S. King & Son, London, Eng., 

1910, pp. 434; price $3.00. 



316 A TEACHER'S PRIVATE LIBRARY 

12. Leland, Arthub: Playground Teaching and Playcraft; 
price $2.70. 

13. Rapeer, Louis W.: School Health Administration. 
Teachers College, 1913, pp. 360; price $2.25. 

14. Terman, Lewis M.: The Hygiene of the School Child. 
Houghton Mifflin Co., Boston, 1913, pp. 450; price $1.65. 

15. Terman, Lewis M.: The Teacher's Health. Houghton 
Mifflin Co., Boston, 1913, pp. 138; price $.60. 

16. Proceedings of the Fourth International Congress of 
School Hygiene, held at Buffalo, 1913, three volumes; 
price $5.00. Address Thomas A. Storey, College of the 
City of New York. 

B. The Teaching of Hygiene 

(A selected list of the best books, which retail for a total of 

$6.83). 

1. Gulick, Luther H.: The Gulick Hygiene Series. Ginn 
& Co., Boston. " Two-Book Course," $1.05; " Five- 
Book Course," $2.30. 

2. Hoag, E. B.: Health Studies. D. C. Heath and Co., 
Boston, 1909, pp. 223; price $.60. 

3. Hutchinson, Woods: The Woods-Hutchinson Health 
Series, two volumes, Houghton Mifflin Co., Boston; 
"Book One: The Child's Day," $.40: "Book Two: 
Handbook of Health," $.65. 

4. Ritchie and Caldwell: Primer of Hygiene, and Primer 
of Sanitation. World Book Company, Yonkers-on-Hud- 
son, New York. The two for $1.08. 

5. Wood and Reesor: Health Instruction in the Elementary 
Schools. Teachers College, New York, 1912, pp. 140; 
price $.25. 

6. Tolman and Guthrie : Hygiene for the Worker. American 
Book Co., 1912, pp. 231; price $.50. 



GLOSSARY 



anaemia, deficiency of blood, 
or of red corpuscles. 

arthritis, inflammation of a 
joint. 

astigmatism, a refractive error 
of vision due to unequal cur- 
vature of the parts of the eye. 

atypical, not typical, excep- 
tional. 

aurist, a specialist in diseases 
of the ear. 

bacteriology, the department 
of zoology which deals with 
bacteria. 

blood-count, referring to the 
number of corpuscles per 
unit measure of blood. 

Bright's disease, a disease of 
the kidneys. 

carious, decayed. 

cervical glands, the lymph 
glands of the neck. 

chorea, "St. Vitus's Dance." 

conjunctivitis, an inflamma- 
tory disease of the mucous 
membrane lining the eyelids. 

dentine, the calcified sub- 
stance which composes the 
main part of a tooth. 

desquamation, peeling-off of 
the skin. 

eugenics, the science of im- 
proving the human race 



through the application of 
the laws of heredity, 
exhalation, the expulsion of air 
from the lungs. 

fomite infection, the spread of 
contagious diseases through 
the medium of articles or 
things. 

haemoglobin, that part of the 
red corpuscles whose func- 
tion is to carry oxygen. 

hydrocephaly, a disease char- 
acterized by the accumula- 
tion of a watery fluid on the 
brain. 

hyperopia, "far sight." 

hypertrophied, abnormally en- 
larged, overgrown. 

hyphosis, backward curvature 
of the spine. 

impetigo, a contagious skin dis- 
ease due to a fungus. 

lassitude, weakness or languor, 
lymphatic, pertaining to the 
lymph. 

mastoid, that part of the tem- 
poral bone situated directly 
behind the ear. 

moron, that grade of feeble- 
mindedness just below the 
normal. 

myopia, "near sight." 



318 



GLOSSARY 



neurosis, any nervous disor- 
der. 

oculist, a physician skilled in 
treating diseases of the eye. 

optician, one who makes or 
deals in optical instruments 
or glasses. 

oral hygiene, the hygiene of the 
mouth. 

orthodontia, mechanical treat- 
ment for correcting irregu- 
larity of the teeth. 

otitis media, acute infection of 
the middle ear. 

passee, faded, worn out. 
pediculi capitis, head lice, 
poliomyelitis, a disease of the 

gray matter of the spinal 

cord, 
polypus, a tumorous growth on 

the mucous membrane, as of 

the nose. 



radiograph, an X-ray picture, 
rickets, a nutritional disease of 

childhood affecting chiefly 

the bones. 

scabies, itch. 

scoliosis, lateral curvature of 

the spine, 
squint, cross-eye, or strabismus, 
strabismus, cross-eye. 
suppuration, producing pus. 

tie, a spasmodic twitching of 
the muscles. 

toxaemia, a poisoned condition 
of the blood. 

trachoma, a contagious disease 
of the eye involving granula- 
tion of the inner surface of 
the eyelids. 

varicella, chickenpox. 
Von Pirquet test, a test for the 
presence of tuberculosis. 



INDEX 



Addams, Jane, 52. 

Adenoids, 97 ff. 

Air, as a source infection, 141 ff. 

Australia, school health work in, 

299. 
Ayres, Leonard P., 7, 198. 

Binet tests, 105 ff. 

Blood tests, at open-air schools, 

203 ff. 
Board of health, 25 /. 
Bradford, school medical clinic, 

112; open-air school, 200. 
Burnham, Dr. W. H., 271. 

Cabot, Dr. R. C, 59 

Canada, school health work in, 
298. 

"Carriers," 142/., 160/. 

Chapin, Dr., 141, 143, 154, 160. 

Chickenpox, 171, 192. 

Christian Science, 11 ff. 

Cleaning, method of, 214 ff. 

Clinics. See School clinics. 

Closure of schools, 142 ff. 

Contagious diseases, 133 ff.; 
modes of infection, 137/.; an- 
nual curve, 145. 

Cornell, Dr. W., 308. 

Cups, drinking-cups, 139/. 

Defectiveness, 91/., 253; amount 
of, 2, 87 /.; discovery by 
teachers, 68 /.; treated by 
school clinics, 111 /. See also 
Eyes, Ears, Teeth, Nutrition, 
Nose, Throat, etc. 

Denmark, school health work in, 
295. 

Dental caries, 130/ 

Departments of health in the 
school, Iff., 305/ 

Diphtheria, 135, 143, 159/., 184, 
194. 



Disinfection, 152. 
Dock, Dr., 178-79. 
Dust, 209/ 
Dustless crayon, 216. 

Earache, 80. 

Ears, 71, 115. 

England, school health work in, 

285/ 
Epidemic meningitis, 181 / 
Eyes, 72, 80, 84 /., 92 /, 116, 

182/ 

Favus, 189. 

Feeble-mindedness, 105/ 

Feeding, in open-air schools, 199. 

Flexner, 182. 

Fomite infection, 137 / 

Food, 88. 

Food habits, 228. 

Forsyth Dental Infirmary, 128. 

Foster, Dr. N. K., 309. 

France, school health work in, 

290/. 
Fiirst, Dr. Clyde, 286. 

Germany, school health work in, 

287/ 
Gonorrhoea, 252-53. 

Haberlin, Dr., 204. 

Hall, Stanley, 254. 

Hall, W. S., 228. 

Hay ward, Dr., 49. 

Headache, 80. 

Health supervision, relation of, 
to private medical practice, 
6 / ; opposition to, 11/; de- 
velopment of, 15 /., 285 /; 
scope of, 17/; cost of, 23, 45 
/.; method of control, 25 /.; 
state departments, 37 /.; or- 
ganization of city departments, 
41/, 305/; by nurses, 48/; 



320 



INDEX 



influence on home, 54 /.; by 
teachers, 62 ff.; in foreign 
countries, 285 ff. 

Hearing, test of, 99 ff. See also 
Ears. 

Hoag, Dr. E. B., 90, 145, 315. 

Hogarth, Dr. A. H., 109, 121. 

Hookworm disease, 178 ff. 

Home, influence of health super- 
vision on, 10 ff.; sanitation of, 
241 ff.; responsibility for sex 
enlightenment, 267. 

Hygiene departments, of city 
schools, 305 ff. 

Hygiene teaching, 9, 103, 231 ff.; 
in the first six grades, 221 ff. ; 
in the seventh and eighth 
grades, 236 ff.; by means of 
sanitary surveys, 240 ff.; sex 
education, 252 ff.; teacher's 
hygiene library, 315-16. 

Impetigo, 190. 
Infantile paralysis, 180 ff. 
Influenza, 194-95. 
Intelligence tests, 105 ff. 
Ireland, school health work in, 

297. 
Itch. See "Scabies." 

Janitors, 219. 

Japan, school health work in, 

299. 
Jessen, Dr. E., 125. 

Kerr, Dr. James, 148, 154. 
Korosi, Dr., 133. 

Lambert, Dr., 213. 

"League for Medical Freedom," 

11/- 

London, school clinics in, 112. 

McCallie test, 96. 
Mackenzie, Dr. W. Leslie, 297. 
MacMillan, Margaret, 112. 
Malnutrition, 176. 
Measles, 134, 149 ff., 192. 
Medical inspection. See "Health 

supervision." 
Mental conditions, 83, 105/. 



Milwaukee, school health work 
in, 305/. 

Minneapolis, health organiza- 
tion in, 307. 

Minnesota, state division of child 
hygiene, 38 ff. 

Moll, Dr. Albert, 254. 

Moral Education, 260. 

Mumps, 169 ff., 194. 

Muroscroll, 216. 

Nervous conditions, 70, 83. 

New York City, school health 
department, 310/. 

Normal schools, and the teach- 
er's health, 281. 

Norway, school health work in, 
295. 

Nose and throat, 71, 81, 97/. _ 

Nurses, 42 /. ; 48 /. ; home visi- 
tation, 49/.; and absence, 51 
/.; number, 56 /.; training, 
57/; efficiency, 59/; health 
surveys, 66/ 

Oakland, school health depart- 
ment, 309 / 
Open-air schools, 198 /. 
Orthodontia, 130. 
Osier, Dr., 54, 181. 

Parental responsibility, 3 /. 
Parents, notification of, 104 /. 
Pediculosis capitis, 188/ 
Philadelphia, school health de- 
partment, 308/ 
Physiological age differences, 102 

/ 
Porter, Dr. Langley, 177. 
Posture, 82. 
Publicity, 33/. 

Rapeer, Dr. Louis, 17, 59. 
Records, 29/, 74/ 
Reinhart, Dr. George, 143. 
Ringworm, 189. 

Sanitary surveys, 238. 
Sanitation, 209 / 
Scabies, 187. 
Scarlet fever, 153/., 192. 



INDEX 



321 



School buildings, 8. 

School clinics, demonstration 
clinics, 90 ff . ; medical clinics, 
109/.; cost of, 113; why neces- 
sary, 114; dental clinics, 125 

/■ 

School nurse. See Nurse. 

Scotland, school health work in, 
296. 

Skin diseases, 72, 85. 

Sleep, at open-air schools, 199, 
205. 

Smallpox, 173 ff., 194. 

Snellen test, 84, 95. 

Social responsibility for health, 
Iff., 119 ff. 

State departments of school hy- 
giene, 38/. 

Superannuation of teachers, 272. 

Sweden, school health work in, 
293/. 

Switzerland, school health work 
in, 292. 

Syphilis, 253. 

Teacher, part in health super- 
vision, 62 ff.; private library 
in school hygiene, 315. 

Teacher's health, 270/. 



Teeth, 71, 78, 85; dental clinics, 
125 ff. 

Terman, Lewis M., 108, 270, 303, 
316. 

Towels, 138. 

Trachoma, 97, 185 ff. 

Tuberculosis, 175; among teach- 
ers, 273. See also Open-air 
schools. 

Vaccination, 174. 

Vacuum cleaners, 215. 

Varicella, 171. 

Virginia, school health work in, 
40/. 

Vision, testing, 95 /. See also 
Eyes. 

Vocational guidance for teach- 
ers, 283. 

Von Pirquet test, 175. 

Weight, increase in open-air 

schools, 200. 
Whooping-cough, 164, 166/. 
Wichmann, Dr., 276. 
Wiesbaden, examination plan, 

288. 
Williams, Dr. Lewis, 111, 114, 

119, 120. 



mSm&JE m CONGRESS 



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